Systems for automatically removing fluid from multiple regions of a respiratory tract

ABSTRACT

Systems and devices for monitoring, detecting, and removing fluid build-up found at various regions along a tracheal tube of an intubated patient. The fluid management system includes pressure and flow sensors for detecting whether there is fluid at the various regions along the tracheal tube, and a means for drawing out the fluid into collection jars. The system also includes lavage features that is able to rinse different the various regions along a tracheal tube. Also disclosed are respiration insertion devices that either couple to existing tracheal tubes or incorporate tracheal tubing, where the respiration insertion body has channels and ports that contact various regions along the tracheal tube. The combination of the fluid management system and the respiration insertion devices effectively monitor and remove fluid at various locations along a tracheal tube of an intubated patient.

CROSS REFERENCE TO RELATED APPLICATION

This application is a continuation of U.S. patent application Ser. No.15,696,146, filed Sep. 5, 2017, titled “SYSTEMS FOR AUTOMATICALLYREMOVING FLUID FROM MULTIPLE REGIONS OF A RESPIRATORY TRACT,” now U.S.Pat. No. 10,695,516, which is a continuation-in-part of U.S. patentapplication Ser. No. 14/826,114, filed on Aug. 13, 2015, and titled“SYSTEMS FOR AUTOMATICALLY REMOVING FLUID FROM MULTIPLE REGIONS OF ARESPIRATORY TRACT,” (now U.S. Pat. No. 9,750,910), which claims priorityto India Provisional Application No. 3988/CHE/2014, filed on Aug. 14,2014, entitled “DEVICE AND METHOD FOR REMOVAL OF SECRETIONS TO PREVENTVENTILATORASSOCIATED PNEUMONIA.” The disclosure of each of theseapplications is herein incorporated by reference in its entirety.

INCORPORATION BY REFERENCE

All publications and patent applications mentioned in this specificationare herein incorporated by reference in their entirety to the sameextent as if each individual publication or patent application wasspecifically and individually indicated to be incorporated by reference.

FIELD

The present disclosure relates generally to fluid management apparatusesincluding or for use with tracheal tubes and related devices. Moreparticularly, the disclosure relates to fluid management systems thatare able remove secretions and monitor blockages from crucial pointsalong an endotracheal tube either continuously or at predefinedintervals. When a blockage is detected, the system is able to then clearthe blockage. Fluids and mucous can then be collected for analysis.Devices are respiration insertion devices that monitor and remove fluidat different regions along a tracheal tube.

BACKGROUND

Tracheal tubes are inserted into the airway of patients in medicalsituations where the patient is unable to breathe on his own due toobstructions or lack of awareness/consciousness on the patient's part.Tracheal tubes aid in mechanically ventilating patients until thepatients are able to breathe on their own. Most tracheal tubes currentlyin use include an inflatable cuff or balloon between the tracheal tubeand the walls of the patient's trachea. The balloon or cuff blocks offthe airway passage and establishes a closed system where gas pressure tothe patient's lungs can be more easily regulated and the cuff or balloonhelps to prevent passage of fluids and debris into the patient'strachea. FIGS. 1A-1B show typical respiratory tract locations wherefluid might build in an intubated patient. While FIG. 1A shows thatprimary fluid accumulation typically occurs above an inflatable cuff ofa tracheal tube, FIG. 1B shows that other regions along the trachea ofan intubated patient may also be susceptible to fluid accumulation.

A major complication associated with intubation and the use of trachealtubes is ventilator-associated pneumonia (VAP). VAP is a type of lunginfection that occurs in patients who are placed on ventilators. VAPtypically affects those who are already weak, such as patients in anintensive care unit (ICU) and/or with compromised immune systems.Developing VAP can increase the length of time a patient is in the ICUand the hospital. VAP also increases the likelihood of death by 20-30%.

VAP generally occurs because the tracheal tube allows passage ofbacteria into the lower portions of the lung in an intubated patient.These patients may already have underlying issues that decrease theirresistance to bacteria. Bacteria may thrive in the fluid accumulatedaround the tracheal tube, especially where there are bends in thetracheal tube which allow fluid to accumulate. Thus the initial bend inthe tracheal tube between the back of the oral cavity and just past thepharynx, as well as the area above the inflatable cuff or balloon, maybe especially prone to fluid and mucous accumulation. When patientsremain on a ventilator for extended periods, the risk of bacterialinfection increases. Further, bacteria also may be drawn down towardsthe lung when breathing. In addition, the bacteria that cause VAP can bedifferentiated from bacteria that cause the more commoncommunity-acquired pneumonia (CAP). Several bacteria associated with VAPare resistant to commonly-used antibiotics. Thus it would be desirableto minimize the amount of fluid collecting along the tracheal tube thatcan provide a hospitable media for bacteria to grow.

Existing mechanism for addressing the fluid build-up around a trachealtube are not adequate. In the majority of currently available anddescribed systems, the apparatus is only designed to draw fluid awayfrom the tracheal tube at one location or if there is potential for morethan one location of suction along the tracheal tube, the additionalarea is limited to the region immediately above the inflated cuff orballoon. In some variations ports are disposed along a tracheal tube attwo locations, but these locations are not associated with specificanatomical locations on a patient. For example, U.S. Pat. No. 8,434,488('488) describes a tracheal tube with multiple ports that are integratedwith the main tracheal tube opening. The tracheal tube in '488 includesonly one suction lumen where the suctioning occurs in slightly distal tothe cuff. The '488 tracheal tube also includes a line for inflating thecuff and maintaining a certain pressure within the cuff. FIGS. 1C and Dshows traditional fluid management systems where suction only occurs atthe region directly above the inflatable cuff. In addition, traditionalfluid management systems require the caregiver to manually suction outany fluid present throughout the course of time that a patient isintubated, which requires more staff time of an already short-staffedhealth system.

Thus, there exists a need for fluid management apparatuses for use withventilation that can monitor for fluid accumulation along differentregions of a respiratory (e.g., tracheal) insert and automatically andperiodically remove fluid.

SUMMARY OF THE DISCLOSURE

The present invention relates to apparatuses (including systems anddevices) and methods for periodically (and automatically) removing fluidaccumulation at two, three or more regions along a respiratory insertiondevice (e.g., tube, such as an endotracheal tube) that are most likelyto collect fluid, so that any accumulated fluid may be removed. Theseapparatuses may also be configured to flush the fluid lines and/orprovide a lavage to the patient.

Certain regions (corresponding to the patient's anatomy) along arespiratory insertion device (such as an endotracheal tube, tracheostomytubes etc., which may be referred to herein for convenience as a“tracheal tube”) are prone to fluid collection, particularly wheninserted into a patient in a 30 degree reclined/horizontal positionwhich is common. Three identified regions include the subglottic region,which may be directly above an inflatable balloon or cuff on a typicalendotracheal tube, an oropharynx cavity located past the oral cavity,and in the oral cavity. Being able to remove fluid build-up in two orall of these three regions will significantly reduce the likelihood ofVAP in an intubated patient. In particular removal of fluid from theoral cavity and the oropharynx cavity would represent a substantialimprovement in patient care.

The fluid management apparatuses described herein can automaticallyremove fluid from multiple regions of the respiratory tract of apatient, and/or may provide fluid (lavage) to one or more regions. Insome variations, the fluid management apparatus (e.g., system) can bemanually controlled to remove fluid from one or more different regionsalong a tracheal tube. Also discussed herein are respiratory insertiondevices that may attach to the fluid management system, although thefluid management apparatuses described herein may also be configured tooperate with existing commercially available respiratory insertiondevices (e.g., endotracheal tubes and tracheostomy tubes). In addition,also described herein are respiratory insertion devices that areconfigured to be positioned over an existing endotracheal tube,including in particular an endotracheal tube that has already beenpositioned in a patient's body, without harming or hurting the patient.

A fluid management system may include an input (e.g., button,touchscreen, dial, switch, etc.) that is able to receive user-selectedcontrol information such as lavage delivery frequency, lavage duration,lavage pressure, suction application frequency, and suction pressure. Insome variations, the user can set the pressure threshold for determiningwhether there is a blockage within a fluid line connected to arespiratory insertion device. The thresholds may also be pre-set. Forexample, pre-set values may be set by the manufacturer. The thresholdvalues for pressure may be the same for each of the separate lines, butdifferent pressure values for different lines may be selected in somevariations.

The fluid management apparatuses described herein may also have othercontrol and sensing components. This may include suction valves that arein fluid communication with sensors and suctioning mechanism. Valves maycontrol the flow of fluid within the fluid lines. These apparatuses mayalso include flow and pressure sensors that detect either or both thepresence of fluid in a particular line, and/or blockage within the fluidlines as well as monitor when all the fluid has been removed from aparticular region. The system may also include filters before and/orafter the valves and sensors connected or connectable to one or morefluid lines. The filters may minimize contamination reaching the valvesand sensors.

The apparatuses described herein may automatically remove fluid frommultiple regions along a respiratory tract. The system may also beconfigured to lavage an oral cavity portion of the respiratory tract. Insome variations, the system includes controller circuitry, a display,and one or more valves configured to couple to a source of air pressure.The system may also include a first, a second, and a third fluid line,wherein the first, second and third fluid lines couple with the one ormore valves of the controller and wherein the controller is configuredto independently apply positive or negative pressure through each of thefirst, second or third fluid lines. The first fluid line can couple to afirst flow sensor and a first pressure sensor, the second fluid line cancouple to a second flow sensor and a second pressure sensor, and thirdfluid line can couple to a third flow sensor and a third pressuresensor. The flow sensors can be outside of their respective fluid lines.In some variations there are 4 fluid lines, with an additional fluidline as well as the three (oral, oropharynx and subglottic) linesmentioned above. The additional fluid line may remove secretions frominside the respiratory insertion device (e.g., endotracheal tube) eitherby using a closed suction catheter or using a modified respiratoryinsertion device with an additional lumen at the distal end facinginwards to remove secretions from inside the respiratory insertiondevice (e.g., endotracheal tube).

The fluid management system's controller circuitry may be configured toperiodically, automatically, and independently apply negative pressureand/or positive pressure to each of the first, second and third fluidlines (and in some variations additional fluid lines, such as a fourth,or tracheal, fluid line), and to stop applying negative pressure in thefirst, second or third fluid lines when fluid flow in the first, secondor third fluid line is below a first flow threshold and when pressure inthat fluid line is above a first pressure threshold. The controllercircuitry may also apply positive pressure to the first, second or thirdfluid lines when the fluid flow is below the first flow threshold whenapplying negative pressure and the pressure is below a second pressurethreshold in the first second or third fluid lines. Finally, thecontroller circuitry may be configured to display for one or more of thefirst, second and third fluid lines data comprising one or more of flowrate of a secretion within the fluid line, thickness of secretion withinthe fluid line, volume of secretion within the fluid line, or color ofthe secretion within the fluid line.

The fluid management system may also include a lavage system (orsub-system). The lavage system (sub-system) may apply positive pressureto deliver a lavage fluid through one of the fluid lines (e.g., the lineconnected to the region of the respiratory insertion device within theoral cavity) and to apply negative pressure to one or more other of thefluid lines to remove the lavage fluid. The pump may be in communicationwith the controller and the source of lavage fluid and can be signaledto provide positive pressure to the fluid lines. The system may includea plurality of fluid lines that directly connect (or they may beconnected via separate one or more lavage delivery fluid lines) to thesource of lavage liquid. The controller may signal the lavage pump toapply positive pressure to the one or more lavage delivery fluid linesto deliver lavage fluid. Any of these apparatuses may also include oneor more receptacles for holding returned lavage fluid.

Thus, any of these systems may also include a source of lavage fluid(e.g., antibacterial mouthwash, etc.), where the controller isconfigured to automatically apply positive pressure to deliver lavageliquid at a lavage delivery frequency; and a first collection containercoupled to the first fluid lines to collect fluid from the first fluidline, a second collection container coupled to the second fluid line tocollect fluid from the second fluid line, and a third collectioncontainer coupled to the third fluid line to collect fluid from thethird fluid line.

As mentioned above, these apparatuses may also include an inputconfigured to receive user-selected control information, which mayinclude (or be limited to) control information regarding suction and/orlavage, including: lavage delivery frequency, lavage duration, lavagepressure, suction application frequency, suction duration, and suctionpressure.

In general, any of these apparatuses may also include one or morefilters, wherein one or more valves is in communication with fluid linesthrough the one or more filters. The valves may be suction valves, wherea first suction valve is between the first fluid line and the source ofair pressure, a second suction valve is between the second fluid lineand the source of air pressure and a third suction valve is between thethird fluid line and the source of air pressure.

As mentioned, the apparatus may also include one or more lavage deliveryfluid lines that are connected to the source of lavage liquid andwherein the controller is configured to apply positive pressure to theone or more lavage delivery fluid lines to deliver lavage fluid. Theapparatus may also include a pump configured to apply positive pressure,wherein the pump is in communication with the controller and the sourceof lavage fluid. Thus, the controller may be configured to applypositive pressure to deliver the lavage fluid through the first fluidline and to apply negative pressure to the first, second and third fluidlines to remove the lavage fluid. Finally the apparatus may include avessel for collecting the used lavage fluid.

The fluid management systems described herein may also include anoutput, such as a display (e.g., screen, monitor, etc.), where dataregarding the first, second, and in some variations, a third, fourth, oradditional fluid lines are shown. Data can include flow rate of asecretion within the fluid line, thickness of secretion within the fluidline, volume of secretion within the fluid line, or color of thesecretion within the fluid line.

Any of these apparatuses may include collection containers. One or more,e.g., a first, second and third (and in some variations a fourth)collection container, may be coupled to a first, second, and third fluidline, where each is connected to a valve of the one or more valves andthe source of air pressure.

The respiratory insertion device extends distally along its major axis.The respiratory insertion device includes a first and a second lumenwhere the first and second lumen includes a first and a second openingin fluid connection with the first and the second lumen, respectively.The first and second opening are located spatially from each other alongthe tracheal tube such that two regions along the tracheal tube prone tofluid accumulation correspond to the location of the first and secondopening. In some cases, the first and the second opening are at least0.4 inch from each other. In other examples, a third lumen having acorresponding third opening is also disposed along the tracheal tube ina region away from and not in the regions corresponding to the locationof the first and the second openings of the first and second lumen.

The first, the second, and potentially a third lumen all include a meansfor fluidly connecting to corresponding fluid lines at an oppositeterminus from their respective openings. The fluid lines are coupled toa suctioning apparatus, such as a pump, that is able to draw fluid awayfrom the regions associated with the first, second, and third openings.There may be separate fluid lines that connect to the first, the second,and the third lumen or there may be one fluid line that serves to removefluid from all the lumen present using appropriate connectors.

The fluid management system also includes a controller that is inelectrical communication with the sensors, the pump or pumps, valves andother components. The controller periodically will test for fluid ormucous blockage within the different lumen that correspond to thedifferent regions of the tracheal tube. If blockage is detected thecontroller will communicate to the pump(s) to apply positive and thennegative pressure to clear away the fluid and mucous.

In general, a tracheal tube is a catheter that is inserted into thetrachea for the primary purpose of establishing and maintaining a patentairway and to ensure the adequate exchange of oxygen and carbon dioxide.Many different types of tracheal tubes are available, suited fordifferent specific applications, including endotracheal tubes andtracheostomy tubes. For example, an endotracheal tube (ET) is typicallya specific type of tracheal tube that is nearly always inserted throughthe mouth (orotracheal) or nose (nasotracheal). A tracheostomy tube isanother type of tracheal tube, which may be, e.g., a 2-3-inch-longcurved metal or plastic tube that may be inserted into a tracheostomystoma (following a tracheotomy) to maintain a patent lumen. Therespiratory (or in some variations, endorespiratory) insertion devicesdescribed herein may be tracheal tubes or they may be adapted for usewith a tracheal tube, as described in greater detail below.

The system can couple to a respiratory insertion device (which may alsobe referred to as a respiratory insertion body), where the respiratoryinsertion device extending distally in an elongate axis, the respiratoryinsertion device may include a plurality of lumen extending in theelongate axis, and a plurality of openings, wherein each lumen is influid connection with an opening, and where the openings for differentlumen are separated along the elongate axis by at least 0.4 inches. Ingeneral, each of the lumen in the plurality of lumen are configured tofluidly connect with one of the first, second or third fluid lines. Asdescribed in detail below, in some variations the systems describedherein may include additional fluid lines, and in particular a fourthfluid line that is configured to attach to a lumen in a tracheal devicethat may be connected to remove fluid from within the central and/ormain lumen of the tracheal tube. This may be referred to as a trachealline.

As mentioned, the respiratory insertion devices described herein may betracheal tubes or they may connect to an existing tracheal tube. In theformer case where the tracheal tube incorporates the fluid managementfeatures, the respiratory insertion device may have three or more (e.g.,4) integrated lumens along with the main tracheal tube passageway, e.g.,the three lumens for the locations already mentioned and a fourth lumento remove secretions from inside the main tracheal tube. As previouslymentioned, suction of pre-determined regions along the tracheal tubepath is through openings along the respiratory insertion device. In thelatter case, where the respiratory insertion device attaches to anexisting endotracheal tube, several examples are described herein. Inone example, the respiratory insertion device can clip onto an existingendotracheal tube and be slid down along the length of the trachealtube. The respiratory insertion device clip includes separate lumenhaving corresponding openings that contact pre-determined regions alongthe tracheal tube. In some variations of the respiratory insertiondevice clip may have a hinge for easier placement of the respiratoryinsertion device.

The respiratory insertion body can independently remove fluid frommultiple regions of a respiratory tract. The respiratory insertion bodymay have an elongate axis extending proximally to distally with a firstlumen disposed along the elongated body having a first lumen proximalend and a first lumen distal end, a second lumen disposed along theelongated body having a second lumen proximal end and a second lumendistal end, and a third lumen disposed along the elongated body having athird lumen proximal end and a third lumen distal end. In somevariations, the apparatus may include a first, second, and third openingdisposed respectively on the first, second, and third lumen distal end.The first, second and third openings may be positioned along theelongate body so that the first, second and third openings are separatedfrom each other by at least 0.4 inches along the elongate axis. Thefirst opening in respiratory insertion body may be configured to bepositioned in the oral cavity of a user, the second opening isconfigured to be positioned at a oropharynx region of the user, and athird opening through the endotracheal insertion body is configured tobe positioned at a subglottic region of the user when the endotrachealinsertion body is inserted into the user's throat. In some examples, theelongate body comprises a tubular body having a central tracheal tubelumen opening at a proximal end and a distal end of the endotrachealinsertion body. In other examples, the elongate body comprises a sheathconfigured to connect over an endotracheal tube. The elongated body mayalso be a spiral sheath configured to connect over an endotracheal tube.In some cases, a series of clips/attachments that can fit over anendotracheal tube. In general, the first lumen proximal end, the secondlumen proximal end, and the third lumen proximal end each comprise afluid line coupler configured to attach to a fluid line. Finally, firstopening is between about 3 cm and 14 cm from the third opening, andfurther wherein the second opening is between about 2 cm and 10 cm fromthe third opening.

Some of the respiratory insertion devices described herein are forcoupling to tracheostomy tubes or may incorporate a tracheostomy tube.In one case, the insertion device has a bifurcated elongate body havinga first arm and a second arm, the body having an elongate axis extendingproximally to distally. The first arm is configured to extend through alumen of the tracheal tube and comprises a bent distal end regionconfigured to extend out of a distal end of the tracheostomy tube, wraparound the distal end of the tracheal tube and extend proximally up thetracheal tube. The second arm is configured to extend distally along theoutside of the tracheal tube. A first and second opening disposed withinthe first arm of the elongated body. The first opening is disposedproximal to the bent distal end region of the first arm and configuredto reside within the lumen of the tracheal tube. The second opening maybe disposed distally to the bent distal end region and configured toreside outside of a distal end region of the tracheal tube. A thirdopening may be disposed on a third lumen within the second arm, thethird opening disposed near a distal end of the second arm. The proximalend of the first lumen may comprise a first fluid line couplerconfigured to attach to a first fluid line, a proximal end of the secondlumen comprises a second fluid line coupler configured to attach to asecond fluid line and a proximal end of the third lumen comprises athird fluid line coupler configured to attach to a third fluid line.

In another example, a respiratory insertion device includes anintegrated tracheostomy tube. Here the insertion device may have anelongate body, the body having an elongate axis extending proximally todistally, an inflation cuff near a distal end of the elongate body, acentral lumen within the elongate body, a first lumen extendingproximally to distally along the elongated body having a first openingfacing inwards towards the central lumen/passageway (between the firstlumen and a central lumen that serves as a tracheal tube), a secondlumen extending proximally to distally along the elongated body having asecond opening into the second lumen on an outside of the elongated bodydistal to the inflation cuff, and a third lumen extending proximally todistally along the elongated body having a third opening into the thirdlumen on an outside of the elongated body proximal to the inflationcuff. Similar to previous examples, a proximal end of the first lumenmay comprise a first fluid line coupler configured to attach to a firstfluid line, a proximal end of the second lumen may comprise a secondfluid line coupler configured to attach to a second fluid line and aproximal end of the third lumen may comprise a third fluid line couplerconfigured to attach to a third fluid line.

Another example of a system for automatically removing fluid frommultiple regions of a respiratory tract (and in some variations,lavaging an oral cavity portion of the respiratory tract) may include: acontroller comprising: controller circuitry, a first pressure sensor, asecond pressure sensor, a third pressure sensor, a first port incommunication with the first pressure sensor and configured to connectto a first fluid line, a second port in communication with the secondpressure sensor and configured to connect to a second fluid line, athird port in communication with the third pressure sensor configured toconnect to a third fluid line, and one or more valves configured tocouple to a source of air pressure; a first optical flow sensorconfigured to couple to an outside of a first fluid line to detect flowwithin the first fluid line; a second optical flow sensor configured tocouple to a second fluid line to detect flow within the second fluidline; a third optical flow sensor configured to couple to a third fluidline to detect flow within the third fluid line; wherein the firstsecond and third optical sensors are housed separately from thecontroller; further wherein the control circuity is configured to detectwhen fluid lines are connected to each of the first, second and thirdports, and to periodically apply negative pressure to each of the first,second and third ports when fluid lines are detected, and to stopapplying negative pressure on the first port when the first optical flowsensor indicates there is no more flow, to stop applying negativepressure on the second port when the second optical flow sensorindicates there is no more flow, and to stop applying negative pressureon the third port when the third optical flow sensor indicates there isno ore flow; further wherein the controller circuitry is configured todetect a blockage in the first fluid line based on the first pressuresensor and the first optical flow sensor, to detect a blockage in thesecond fluid line based on the second pressure sensor and the secondoptical flow sensor, and to detect a blockage in the third fluid linebased on the third pressure sensor and the third optical flow sensor,and to clear a detected blockage.

In general, the optical flow sensors may be separate from thecontroller, and may be part of a second (or more) smaller,sub-assemblies that are connected (by wire or wireless connection) tothe controller and controller circuitry. For example, the optical flowsensors may be housed in a separate housing that is configured toenclose the fluid lines and detect flow in each of the fluid lineswithout contacting the inner lumen of the fluid lines, e.g., through thewall of the fluid lines. This may allow the flow sensors to bepositioned closer to the patient than the controller, e.g., within a fewfeet (e.g., 4 feet or less from the patient, 3 feet or less, 2 feet orless, 1.5 feet or less, 1 foot or less, than 11 inches or less, than 10inches or less, 9 inches or less, 8 inches or less, 7 inches or less, 6inches or less, etc.). The controller may be positioned further from thepatient, e.g., 2 feet or more, 3 feet or more, 4 feet or more, 5 feet ormore, 6 feet or more, etc.). The closer the flow sensors are to thepatient, the more quickly the controller may respond. The flow sensorsmay be positioned in a housing (flow sensor housing). The flow sensorhousing may be configured to enclose around at least a portion of thefluid lines, and/or connect to the fluid lines directly.

For example the controller may be housed in a control housing enclosingthe controller circuitry, the first, second and third pressure sensors,and the one or more valves. The controller housing may be configured forsitting on a table, the floor, or being securely mounted to a pole(e.g., IV pole mount, etc.). As mentioned, the first, second and thirdoptical flow sensors may be housed in a flow sensor housing configuredto be applied around the first, second and third fluid lines, near apatient's head.

The controller may be configured to apply positive pressure to deliver alavage fluid out of the first port and to apply negative pressure to thefirst, second and third port to remove the lavage fluid when fluid linesare detected. The one or more valves of the controller may include afirst, second and third suction valve. The suction sub-system mayinclude a manifold for diving up (and/or separately controlling)negative pressure and/or positive pressure in the various fluid lines,e.g., by regulating pressure in the ports on the controller.

As mentioned, also described herein are respiratory insertion devicesfor use with an endotracheal tube to independently remove fluid frommultiple regions of a respiratory tract. Any of these devices may beconfigured as a disposable or single-use component that can bepositioned over an endotracheal tube that is already worn by thepatient. The respiratory insertion device may therefore be configured oradapted to engage with an endotracheal tube inserted into a patientwithout harming the patient. The respiratory insertion device may beformed entirely of a biocompatible material, and may be removed andreplaced periodically (e.g., every 24 hours, every 36 hours, every 48hours, every 3 days, every 4 days, every 5 days, every 6 days, everyweek, etc.). The respiratory insertion device may be configured to fitover any standard endotracheal tube of CASS endotracheal tube. Inparticular, the respiratory insertion device may include a region of thesheath body that has a C-shaped cross-sectional profile that includes alongitudinal channel to hold the outer body of an endotracheal tube; thelongitudinal channel may include a longitudinal opening or slit that canbe separated for inserting around an endotracheal tube so that theendotracheal tube fits into the longitudinal channel. Typically, thesheath body secures the respiratory insertion device around anendotracheal tube. The sheath body may be a coil-shaped region or ahinged region. The distal end of the respiratory insertion device may beconfigured both to ensure effective suctioning of fluid (e.g., from theback of the oral cavity and/or the oropharyngeal regions, for example),and may also be configured to be formed of a soft material (e.g., havinga durometer of less than 60, Shore A scale, or less than 70, less than75, etc.). The more proximal region, such as the sheath body, may beformed of a relatively harder material (e.g., having a durometer ofgreater than 50, Shore A scale, greater than 60, greater than 70,greater than 75, etc.). The softer distal end region of the respiratoryinsertion device (which may be part of an extension portion, e.g.,extending from the sheath body), may therefore ensure the safe insertioninto the oral cavity. The distal end of the respiratory insertion devicemay be the distal end of the extension portion, and may be rounded (e.g.configured as a rounded foot).

For example described herein are respiratory insertion devices thatinclude: a sheath body having a longitudinal channel with a lateralopening extending proximally to distally wherein the longitudinalchannel is configured to fit over the endotracheal tube; a first lumenpassing through the sheath proximally to distally, wherein the firstlumen extends between a first proximal coupler and a first distalopening; a second lumen passing through the sheath proximally todistally, wherein the second lumen extends between a second proximalcoupler and a second distal opening; a third lumen passing through thesheath proximally to distally, wherein the third lumen extends between athird proximal coupler and a third distal opening; wherein, when thesheath body is coupled to the endotracheal tube, the first, second andthird distal openings are configured to be positioned adjacent to theoutside of the endotracheal tube so and are separated from each other(in the proximal-to-distal direction along the device) by at least 0.4inches.

Any of the respiratory insertion devices described herein may include abite flange extending proud from a proximal end of the sheath body. Thebite flange may be configured as a hard flange that can be held againstthe patient's teeth (e.g., incisor teeth). The bite flange may be theportion of the sheath body that controls the depth to which therespiratory insertion device is inserted over an endotracheal tube thatis already inserted into a patient's mouth. The bite flange may be apart of the sheath body.

As mentioned above, the respiratory insertion device may include adistal end that may be softer than the more proximal portion (e.g., thebite flange of the sheath body). The extension may extend distally fromthe sheath body. The distal end region of the extension may beconfigured to include one or a pair of rounded feet. For example, theextension portion may be configured so that it extends from the sheathbody wrapping around the endotracheal tube and may lie adjacent to theendotracheal tube. As mentioned, the extension may be formed of amaterial that is softer than the sheath body. The extension may includea curved channel that is continuous with the longitudinal channel of thesheath body. This curved channel of the extension may hold theendotracheal tube, but may not enclose it as much as the sheath bodyencloses the endotracheal tube. The distal end region may includeslightly protruding “feet” that may be rounded and may provide thedistal end openings for two or more of the lumen of the respiratoryinsertion device. These feet at the distal end of the projecting regionmay extend from the plane of the distal extension region on either sideof the distal extension region (e.g., at between a 70 and 110 degreeangle relative to the flat or slightly curved plane of the distalextension region, allowing the feed to be positioned on either side ofthe endotracheal tube. The feet (which may also be referred to herein aslegs) may be formed of a soft (e.g., low durometer) material to avoidinjury to mucous membranes an may be configured to reach a level that isjust about the epiglottis after complete insertion of the respiratoryinsertion device over an inserted endotracheal tube.

The first distal opening may be adjacent to a distal end of the sheathbody, the second distal opening may be at a distal end region of theextension on the rounded foot, and the third distal opening may bebetween the first distal opening and the second distal opening and mayface laterally from the rounded foot of the extension.

Any of these respiratory insertion devices may include one or moretongue protection flaps extending laterally from the extension, whereinthe tongue protection flap is adjacent to the third distal opening.

In general, the lumen (e.g. first lumen, second lumen, third lumen,etc.) may each be within a catheter. Separate catheters may enclose thefirst lumen, a second, and third lumen.

In any of the respiratory insertion devices described herein, the distalopenings and lumen may be mirrored along the length of the respiratoryinsertion device that operates and is positioned in parallel as thefirst, second and third lumen. For example, any of the respiratoryinsertion devices described herein may include a fourth lumen that isparallel to the first lumen and passes through the sheath proximally todistally, wherein the fourth lumen extends between the first proximalcoupler and a first distal opening that is adjacent to the distal end ofthe sheath body; a fifth lumen that is parallel to the second lumen andpasses through the sheath proximally to distally, wherein the fifthlumen extends between the second proximal coupler and a fifth distalopening; and a sixth lumen that is parallel to the third lumen andpasses through the sheath proximally to distally, wherein the sixthlumen extends between the third proximal coupler and a sixth distalopening that is between the fourth distal opening and the fifth distalopening.

A respiratory insertion device for use with an endotracheal tube toindependently remove fluid from multiple regions of a respiratory tractmay include: a sheath body having a longitudinal channel with a lateralopening extending proximally to distally wherein the longitudinalchannel is configured to fit over the endotracheal tube; an extensionextending distally from a distal end of the sheath body; a bite flangeextending proud from a proximal end of the sheath body; a first lumenpassing through the sheath proximally to distally, wherein the firstlumen extends between a first proximal coupler and a first distalopening that is adjacent to the distal end of the sheath body; an secondlumen passing through the sheath proximally to distally, wherein thesecond lumen extends between a second proximal coupler and a seconddistal opening that is at a distal end region of the extension; and athird lumen passing through the sheath proximally to distally, whereinthe third lumen extends between a third proximal coupler and a thirddistal opening that is between the first distal opening and the seconddistal opening; wherein, when the sheath body is coupled to theendotracheal tube, the first, second and third distal openings areconfigured to be positioned adjacent to the outside of the endotrachealtube so and are separated from each other by at least 0.4 inches.

As mentioned, the distal end region of the extension comprises a roundedfoot. The extension may comprise a material that is softer than thesheath body. The second distal opening may be at a distal end region ofthe extension on the rounded foot. The third distal opening may facelaterally from the rounded foot of the extension. A tongue protectionflap may extend laterally from the extension that is adjacent to thethird distal opening.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1A illustrates a traditional endotracheal tube (tracheal tube) thathas been inserted into a patient where the arrow shows a pocket of fluidbuild-up.

FIG. 1B illustrates a trachea and a bronchi region, showing differentregions where fluid can collect.

FIG. 1C illustrates a traditional fluid removal set-up that onlysuctions a subglottic region of the patient.

FIG. 1D illustrates a traditional tracheal tube system that requiresmanual suction and subglottic secretion drainage

FIG. 2 illustrates one example of a fluid management system, along witha respiratory insertion device, that automatically and periodicallymonitors and removes fluid from multiple regions along a tracheal tube.

FIG. 3 illustrates an example of a respiratory insertion device of anautomatic fluid removal system inserted through a subject's mouth (shownin cross-section) and the opening created within a patient's trachea.

FIG. 4 illustrates a generic fluid management system as describedherein.

FIG. 5 illustrates one embodiment of a fluid management system that canbe used in combination with various embodiments of a respiratoryinsertion device (three are shown on the right).

FIG. 6 illustrates two aspects of a fluid management system, includingsensing and control components.

FIG. 7 is a block diagram of one embodiment of the fluid managementsystem showing a controller in connection various components (includingthe tracheal tube, a flow sensor, a pressure sensor, a pressure controlmechanism, control valve, vacuum, lavage, a display and a power source).

FIG. 8 is a block diagram of an alternative embodiment of the trachealtube fluid management system for three regions of the trachea having anexternal suction.

FIG. 9 is a block diagram of an alternative embodiment of the trachealtube fluid management system for three regions of the trachea having abuilt-in suction.

FIG. 10 is a circuit diagram of one variation of a fluid managementsystem.

FIG. 11 is a block diagram of an embodiment of a fluid management systemhaving the secretion collection vessels sensing units and a pressuresensor, and having six independent lines including three lines forsuctioning and three lavage lines.

FIG. 12 is a block diagram of another variation of a fluid managementsystem having non-return valves along each independent suctioning line.

FIG. 13 illustrates an alternate embodiment of a fluid management systemhaving the secretion collection jars behind the suctioning values andcontrols.

FIG. 14 illustrates an alternative embodiment of a fluid managementsystem having one collection jar behind the suctioning lines, valves andlavage valves, using 3-way valves.

FIG. 15A illustrates an alternative embodiment of a fluid managementsystem having four independent lines with corresponding sensors.

FIG. 15B illustrates an alternative embodiment of a fluid managementsystem.

FIG. 16A is a pictorial of the closed controller, fluid lines, andsecretion collection reservoir.

FIG. 16B is a close-up pictorial of the controller showingmicrocontroller, valves, pumps and circuitry.

FIG. 16C is yet another close-up pictorial showing controls, controllerhaving suction valves, pressure controller, vacuum, and fluid lines.

FIG. 17 illustrates another representative block diagram of the fluidmanagement system having three independent suctioning lines.

FIG. 18 illustrates various combinations of traditional tracheal tubeand systems with the disclosed fluid management system and an insertionbody.

FIG. 19A shows one variation 19B illustrates a spiral embodiment of arespiratory insertion device.

FIG. 19B illustrates a spiral embodiment of a respiratory insertiondevice.

FIG. 19C illustrates a spiral-shaped respiratory insertion device foruse with a tracheal tube.

FIG. 19D shows a close-up view of regions of the respiratory insertiondevice of FIG. 19A.

FIG. 20 illustrates a hinged embodiment of the respiratory insertiondevice.

FIG. 21 illustrates a stent-like embodiment of the respiratory insertiondevice.

FIG. 22A illustrates a ring-type embodiment of a respiratory insertiondevice with suctioning lumen.

FIG. 22B is an alternative perspective view of the ring-type embodimentof the respiratory insertion device with suctioning lumen of FIG. 22A.

FIG. 22C is an enlarged drawing of a portion of the ring-type embodimentrespiratory insertion device with suctioning lumen.

FIG. 23A illustrates a front view of an alternative embodiment of a cliprespiratory insertion device.

FIG. 23B illustrates a side view of the alternative embodiment of theclip respiratory insertion device of FIG. 23A.

FIG. 24A is an offset view of yet another embodiment to the cliprespiratory insertion device comprising two materials.

FIG. 24B is a side view of another embodiment to the clip respiratoryinsertion device comprising C-shaped supports.

FIG. 25A is a front perspective view of an embodiment of a respiratoryinsertion device having five channels for lavage and secretion removal.

FIG. 25B is a side view of an embodiment of the respiratory insertiondevice having five channels for lavage and secretion removal.

FIG. 25C is a perspective view of an embodiment of the respiratoryinsertion device having five channels for lavage and secretion removal.

FIG. 26A is a front and perspective view of an embodiment of a cliprespiratory insertion device having stacked lumen.

FIG. 26B is a side view of the free clip respiratory insertion device ofFIG. 26A having stacked lumen.

FIG. 26C is a side view of a clip respiratory insertion device havingstacked lumen engaged with a tracheal tube.

FIG. 27A is a side view of an oropharyngeal airway insertion body.

FIG. 27B is another view of the oropharyngeal airway insertion body.

FIG. 27C is a third view of the oropharyngeal airway insertion bodyshowing suctioning ports.

FIG. 27D shows a section view through the proximal end of the insertionbody of FIG. 27A.

FIG. 28A is a side view of an integrated respiratory insertion deviceshowing a first suctioning region.

FIG. 28B is a side view of the integrated respiratory insertion deviceof FIG. 28A showing a second suctioning region.

FIG. 28C is a side view of the integrated respiratory insertion deviceof FIG. 28A showing a third suctioning region.

FIG. 28D is a depiction of a section through the proximal end of theintegrated respiratory insertion device of FIG. 28A.

FIG. 28E shows a distal end of the integrated respiratory insertiondevice of FIG. 28A.

FIG. 28F shows another view of the respiratory insertion body havingthree ports along its main body.

FIG. 28G shows a cross-section of the respiratory insertion body ofFIGS. 28A-28F, where an internal port for suctioning the inside of theendotracheal tube is shown.

FIG. 29A is a drawing of a first embodiment of a respiratory insertiondevice for use with a tracheostomy tube.

FIG. 29B shows the respiratory insertion device of FIG. 29A engaged witha tracheostomy tube.

FIG. 30 is an example of an integrated respiratory insertion device withthe tracheostomy tube.

FIG. 31A illustrates another example of a system for automaticallyremoving fluid from multiple regions of a respiratory tract and lavagingan oral cavity portion of the respiratory tract as described herein,including a controller, and a separate flow sensor sub-unit thatcommunicates flow information with the controller. Both an endotrachealtube and a respiratory insertion device that is configured to fit overthe endotracheal tube are shown as well, but may be separate from thesystem, as the controller and flow sensor(s) may be reused withdifferent respiratory insertion devices and endotracheal tubes.

FIG. 31B is another example of a system for automatically removing fluidfrom multiple regions of a respiratory tract and lavaging the patient'soral cavity, similar to that shown in FIG. 31A.

FIGS. 32A-32G shows another example of a respiratory insertion devicefor use with an endotracheal tube to independently remove fluid frommultiple regions of a respiratory tract. In FIG. 32A, the respiratoryinsertion device is shown in a back perspective view, showing the distalportion that is adapted to be inserted over an endotracheal tube alreadyworn in the patient's mouth, and the more proximal catheter tubesconnecting to the lumen for suctioning and/or adding/removing lavagefluid. FIG. 32B shows a side perspective view of the respiratoryinsertion device of FIG. 32A. FIG. 32C show a distal or back view of therespiratory insertion device of FIG. 32A. FIGS. 32D and 32E show top andbottom views, respectively, of the respiratory insertion device of FIG.32A. FIG. 32F is a side view and FIG. 32G is a slightly enlarged view ofthe distal end of the respiratory insertion device of FIG. 32A.

FIG. 33 shows an example of another variation of a respiratory insertiondevice similar to that shown in FIGS. 32A-32G, including a bite flange.

DETAILED DESCRIPTION

Described herein are systems and devices for managing unwanted fluidcollection along a tracheal tube. In general, the fluid managementsystem may include a controller, a plurality of fluid lines, a pluralityof flow sensors, a plurality of pressure sensors, a lavage subsystem,and at least one secretion collection jar. In some embodiments, thefluid management system may also contain a display for showing pressurevalues or keeping a user informed of where within the cycle the systemis during operation. The system may also be adapted to display ananalysis of secretions. Respiratory insertion devices may couple to anyof the fluid management systems described. The respiratory insertiondevices that will be described below may generally function to removefluid build-up along certain regions of a tracheal tube. The respiratoryinsertion devices may be used in conjunction with an existing trachealtube or may perform the function of the tracheal tube includingtracheostomy tube in addition to working to manage fluid collectionalong the respiratory tract. In general, the system may include acontroller, power source, pumps, valves, suctioning devices, sensors,fluid lines, display, and switches.

The system described herein can automatically remove fluid from multipleregions along a respiratory tract. The term automatically may refer toany act or function that is capable of operating independently (e.g.,without ongoing input from a user). In some variations, the termautomatically may indicate that some action is performed without manualintervention. This does not mean that no manual intervention is everrequired, because in the present case, human intervention may be used totrigger or set the process that in all other respects can be automatic.In particular, a user can set the system to run at defined intervals orwhen certain conditions are met.

Fluid may refer to a substance that is capable of flowing andcontinually deforms under applied shear stress. Fluids can includeliquids, gases, plasma, and some solids. As applicable here, the termfluid may be used synonymous with liquid, a substance that has adefinite volume but no fixed shape. Thus, fluids may refer to biologicalliquids secreted from a person's oral and respiratory system, mainlysaliva, mucous, gastric contents and lavage fluid.

Next, the system may include fluid lines that connect the respiratoryinsertion device with the fluid management system. Fluid lines may beany hollow body that can convey fluids, liquids, or gases from onelocation to another (e.g., tubing, channels, etc.). Fluid lines can beformed from metals, glass, rubber, and other synthetic ornaturally-occurring material. Fluid lines may be flexible and formed offluid impermeable, hollow, cylindrical bodies that couple therespiration insertion body to the fluid management system.

The respiratory tract may refer to regions associated with respirationon a mammal, specifically, a human. In general, “respiratory tract” canrefer to the upper respiratory tract and/or the lower respiratory tract.The upper respiratory tract can refer to parts of the respiratory systemabove the glottis (vocal cords) while the lower respiratory tractconsists of the trachea, bronchi, bronchioles, and lungs. Therespiratory tract may refer to the oral cavity, the glottis, thetrachea, and the region directly above the bronchi.

As discussed above, a tracheal tube may refer to a hollow tube that canbe inserted into a trachea of a patient, primarily to establish andmaintain the patient's airway and to ensure adequate respiration. Ingeneral, tracheal tubes may include endotracheal tubes and tracheostomytubes.

A controller may generally refer to a device that can interface withperipheral components and manage how the peripheral components interactand work in connection with each other. The controller may includecircuitry (e.g., chip, chipsets, cards, and the like) for sendingcommands to the components present with the fluid management device. Thecontroller may contain logic gates, routine/subroutines, and datastorage components for running the monitoring and suctioning programs.The controller may also include external user interfaces such asdisplays, buttons, and switches.

Sensors generally refer to a component that can detect a certaincharacteristic of the environment it is in. In particular, describedherein are flow and pressure sensors. Flow sensors may be configured todetect the presence or absence of fluid. Flow sensors can bedifferential pressure flowmeter, velocity flowmeters, positivedisplacement flowmeters, mass flowmeter, or open channel flowmeter, IRbased sensors, capacitive sensors, and UV sensors. Pressure sensors maydetect pressure and may include, but not limited to absolute pressuresensors, gauge pressure sensors, vacuum pressure sensors, differentialpressure sensors, and sealed pressure sensors. Some pressure sensors areforce type sensors that collect a force value to measure strain whenpressure is applied to the area and include piezo resistive straingauge, capacitive, electromagnetic, piezoelectric, optical, andpotentiometric. Other non-force collecting pressure sensors may includeresonant, thermal, and ionization-type pressure sensors. As with anytype of sensor, calibration will help in accurately determining thevalue associated with the condition detected. Finally the flow andpressure sensors may be either internal or external to the fluidmanagement system. One possible position is where the flow and pressuresensors are placed on fluid lines of the system in relative closeproximity to where the system couples to the respiration insertiondevice. Other potential locations for the flow and pressure sensors maybe within the controller unit body.

Lavage may refer to rinsing out a body cavity with water or a medicatedsolution either to clear away unwanted materials or for diagnosticpurposes. As described herein, lavage may occur at variouspre-determined regions along the respiration insertion device. Forexample, the apparatuses described herein may apply lavage to the oralcavity and the oropharynx region on a patient.

Fluid Management Systems

In general, a fluid management system may include fluid lines, sensors,a controller and circuitry for the controller, and lavage components.The controller is typically the portion of the fluid management systemthat oversees operation of the fluid management system components. Thecontroller may contain circuitry and micro-controls for regulating fluidremoval, in the case of suctioning fluids away from a region along thetracheal tube, or fluid delivery in the case of lavage of a certainregion of the oral cavity or respiratory tract where the tracheal tubehas been inserted. The controller may contain valves that connect andmaintain fluid lines that link the respiratory insertion device tosensing, suctioning, and pumping components of the fluid managementsystem. In use, the controller may also include micro-controls thatcontain circuitry for coordinating the sensing, suctioning, and pumpingcycles. The controller periodically, automatically, and independentlyapply pressure, suctioning, or sensing to each fluid line.

The fluid management system also contains fluid lines that connect therespiratory insertion device with the sensing, pumping, and suctioningcomponents of the fluid management system. The fluid lines can bearranged in multiple configurations. In some examples, separate fluidlines connect to each of the ports contained on the respiratoryinsertion device. In other examples, more than one port on therespiratory insertion device can be connected to one fluid line via amulti-port component. The fluid lines should be flexible such assurgical tubing, pressure tubing, or the like. While no preference forfluid line materials are noted here, it would be useful for the fluidlines to be able to withstand suctioning without the walls of the tubingcollapsing or withstanding pressure without having the line break fromthe applied pressure.

The fluid management system typically also contains sensors that allowthe system to determine the presence (e.g., by flow) of secretions inthe fluid line (presumably removed from the pre-determined regions alongthe tracheal tube), and/or to regulate the amount of pressure or suctionbeing applied. Flow and suctioning sensors may be present to sense thepresence/absence of secretions flowing past the sensors. The sensors maybe configured to provide analogue/digital signals to the controller Thefluid management system may then compare the signals sensed withpre-programed values entered by a user or manufacturer to keep thesystem running till it senses the presence of secretions.

The controller may incorporate a power supply that drives the fluidmanagement system components. In the case where the power supply isintegrated into the body of the controller, buttons and switches can befound on the body of the fluid management system that allows the user tocontrol the fluid management system. In other examples, the power supplyis externally maintained and is connected to the fluid management systemwhen in use. The fluid management system may also contain internally orexternally-maintained pumping and suctioning mechanisms.

Next, the fluid management system may include a lavage mechanism forrinsing out a void region associated with the tracheal tube. Lavage ofan area that is in contact with a tracheal tube and where fluid ormoisture may help decrease the amount of harmful microbes that mightaccumulate. While lavage of a patient's oral cavity is most common,lavage of other regions along a tracheal tube such as the oropharynxregion or the subglottic region is also possible. The fluid managementsystem includes fluid lines that connect to the respiratory insertiondevice to deliver and subsequently suction the lavage fluid from thevoid region. The fluid for lavage can be sterile water, saline,chlorhexidine or other suitable solution.

The fluid management system may also contain analysis components thatcan test the fluid withdrawn from the different regions along thetracheal tube of a patient. The fluid management system may containpre-programmed subroutines that may periodically test the withdrawnfluid for certain types of harmful microbes. If detected, the fluidmanagement system may include a way of notifying the doctor or caregiverof the potential for infection based on the positive test for theharmful microbe(s) or analyzing the viscosity, volume and/or color ofthe fluid extracted.

Fluid management systems may also include one or more secretioncollection containers (e.g., jars, chambers, cups, etc.). Secretioncollection jars may be placed in different locations with respect to theother components of the fluid management system as will be discussed inmore detail below. Further, there may be a single secretion collectionjar that collects all the fluid from the different regions along therespiratory insertion device or there may be separate individual fluidcollection jars that correspond to fluid collection from the differentregions. There may also be a separate fluid collection jar for receivinglavage fluid. The fluid obtained may be discarded or sampled to test forpresence of microbes. In some examples, collection jars may also includea fluid level sensor for detecting when the liquid has reached a certainlevel and provide alerts to the user to empty the collection jar orjars.

In use, the system starts with sample suctioning at a predefined timeperiod (which is adjustable and can be set by the physician based on theclinical judgement and condition of the patient). During the samplesuctioning the control unit switches ON the suction valves and thesuction begins for a minimum set amount of time (pre-set by thephysician or manufacturer). During this sample suctioning stage,secretion fluids (saliva, mucous, gastric reflux or any other bodilyfluid) are sucked out up till the sensing unit which is near to the headof the patient. The sensing unit senses the flow/presence of fluid andkeeps the suction ON until it senses that the flow/presence offluid/secretions has decreased to a pre-set value. This fluid getscollected in the collection Jar.

When there are no more fluids/secretions in the patient's oralcavity/oropharynx/subglottic (above the cuff) and/or inside the trachealtube main lumen, the sensor unit may sense the absence of secretions inthe tubing and checks for port blockage by the use of pressure sensor.On detection of port blockage a lavage liquid from the liquid containeris injected in the blocked line by use of the pump and opening thevalves. This fluid injected in the opposite direction to the directionof suctioning, unblocks the port. The injected fluid is immediatelysucked out by use of the suction from the other two lines or by the sameline.

In the case where none of the ports are blocked, the pressure sensordoes not sense port blockage and the system concludes that there are nomore secretions. It then turns off until the next cycle of samplesuctioning.

The sheath/sleeve will have additional ports, or by using the ports inthe oral cavity, lavage liquid is passed through the oral cavity atregular intervals pre-set by the physician (or in some embodiments, themanufacturer) to perform oral rinsing to maintain oral hygiene. Thelavage liquid is suctioned out immediately by the same port/other ports.The device effectively reduces nurses/care givers contact with thepatients trachea and thus reduces the chances of cross infection

The device has built in software to calculate and analyze the volume,flow rate and viscosity of secretions and plot a graph of the patient'ssecretion pattern and detect and predict the onset of infection ordetect early signs of infection. It is also possible to detect pathogenswhere the device has an additional feature of detecting the particularstrain of bacteria/pathogen causing the infection by using microfluidics based technology.

The device can share data through USB, internet, Wi-Fi, Bluetooth,Ethernet, memory stick, or any other data transfer technologies and hasa small printer attachment to print out hard copies of the infectiongraph of the patient

Turning to FIGS. 2 and 4 , a general embodiment of the fluid managementsystem 200 and a respiratory insertion device 270 is shown. In thisparticular example, there are three fluid lines 220 that couple torespiratory insertion device 270. Further discussion of the variousembodiments of the respiratory insertion device and how it connects tothe fluid management system as well to existing tracheal tubes will bediscussed in greater detail below. The fluid management system shown inthis example has an integrated controller 201 that includes flow sensors230 and pressure sensors 240 (not shown). Also included but not shownhere are pressure controls 242 and suctioning/vacuuming controls 232 fordetecting and removing fluid pooling in the pre-set regions along thetracheal tube. Also shown is a single secretion collection jar 260. Aspreviously mentioned, while the fluid management system is capable ofseparately collecting fluid withdrawn from the pre-set regions along thetracheal tube, a user may easily combine the fluid through separatefluid lines 220 into one fluid collection jar 260. FIG. 3 provides abetter view a respiratory insertion device 370 in an intubated patientwith an existing tracheal tube. The pictorial shows a cross-section of apatient's oral, oropharyngeal, and subglottic regions having and regionsalong the tracheal tube and the patient's respiratory tract thatcorresponds to fluid accumulation and where respiration insertion bodycan monitor and remove fluid.

FIG. 4 shows a general schematic of a fluid management system 400 andits major components. The location and connections between thecomponents shown are illustrative and meant to point out to the readergeneral locations of these components. The components may be arrangedand coupled in a variety of ways that are suitable for managing fluidaccumulation in an intubated patient and will be discussed in greaterdetail below.

Finally, any of the fluid management system may incorporate lavage as acomplement to removing fluid secretions around the tracheal tube. Lavagecan be applied to the oral cavity, the oropharynx, or subglottic regionof the patient to moisten areas where saliva would normally bathe butcannot in the case of an unconscious, intubated patient. Lavage can beused to periodically wash the above mentioned regions to clear outdebris and microbes that may cause infection. The fluid and suctioninglines for lavage can be in addition to what is already present forsensing and removing fluid from the oral, oropharynx, and subglotticregions and have separate pumping and suctioning components within orexternal to the controller. In some instances, the lavage lines can tapinto and share existing fluid lines.

FIGS. 5 and 6 show the fluid management system unit as it has beencurrently conceived and reduced to practice. In FIG. 5 , arepresentative number of respiratory insertion devices are shown toindicate that the fluid management system can be used with any of therespiratory insertion devices that will be described below. The overallgoal of the fluid management system is to sense and control the amountof fluid secretions from an intubated patient that collects along thetracheal tube.

The sensing aspect of the fluid management system may contain two typesof sensors. The flow sensors may be used to determine the flow at aparticular instant in the tube, whereas the pressure sensors may be usedto determine port blockage after the flow sensors have detected absenceof secretions. Simultaneously, the pressure sensors can registerpressure values associated with any of the fluid lines connecting to therespiratory insertion device and report the value(s) back to thecontroller. A routine within the controller can be initiated to comparethe detected pressure with preset values such that if the detectedpressure is lesser than the pre-set value, blockage or fluid collectionis indicated at a particular region along the respiratory insertiondevice. Sensors can be placed in any appropriate region, including atthe port openings of the respiratory insertion device or along the fluidlines to sense whether there is fluid present at these locations. Asmentioned, sensors may be non-contact, e.g., configured outside of thefluid line, so that they do not contact fluid within the fluid line(s).If fluid flow (and therefore fluid) is detected and reported back to thecontroller, the controller can initiate a set of instructions forclearing the fluid. In this configuration, the pressure sensor maydetect blockage only in the case when the flow sensors first detect thatthere is no secretions.

The control aspect of the fluid management system regulates themechanical and pressure flow within the system. As FIG. 6 shows,solenoid valves in connection with at least one pump are used to controlthe flow of fluid within the fluid management system and the respiratoryinsertion device. Also maintained within the fluid management systemmodule are electronics for collecting and retaining informationassociated with frequency of monitoring for blockage. There may also beinternal tests that detect presence of potentially harmful microbeswithin any of the fluid lines. Information on the status of the fluidmanagement system can be displayed on an integrated monitor or can beshown on a separate monitor.

A first embodiment of the fluid management system is shown in FIG. 7 . Acontroller 701 links all of the other components present. A respiratoryinsertion device 770 can be an integrated tracheal tube, a sheath, orone of the other arrangements that will be discussed below. Therespiratory insertion device may be arranged as the primary trachealtube or an attachment to an existing tracheal tube within a patient.Respiratory insertion device 770 may include at least two lumen forsuctioning two different regions along a tracheal tube. Respiratoryinsertion device 770 is fluidly connected to the remaining fluidmanagement system 700 components via fluid lines 720. Adjacent torespiratory insertion device 770 are flow sensors 730. Flow sensorsdetect the flow/presence of secretions at an instant at the particularlocation and aid in switching off the device, if they sense absence ofsecretions. The cycle starts at a predetermined time interval and keepsrunning till there is no more flow. Flow sensors 730 are associated witheach line present within respiratory insertion device 770. Flow sensors730 can detect whether there is still fluid present within thecorresponding line within respiratory insertion device 770. Flow sensors730 can automatically and continuously (within the given cycle) detectflow within their corresponding lines as part of a step-wise routine.Alternatively, a user can manually determine flow in any or all of thelines through selecting certain options provided within controller 701.In this present embodiment, the flow sensors 730 are shown to be in linewith other components of fluid management system 700, but in otherexamples, the flow sensors may be associated with separate lumen withinthe respiratory insertion device. The flow sensors can be any suitablesensor that can detect and report back on flow and/or presence ofsecretions within a line. Examples of such sensors may include IRsensors, UV sensors, resistive sensors, capacitive sensors, ultrasoundsensors, and Hall Effect sensors.

Staying with the embodiment shown in FIG. 7 , fluid management system700 also includes pressure sensors 740 and pressure controls 742.Pressure sensors 740 are able to detect the pressure within acorresponding fluid line that connects to a particular lumen of therespiratory insertion device 770. Controller 701 may include routinesthat test the pressure within the fluid lines automatically andperiodically or manually at the request of the user. Pressure controls742 may either create negative pressure within a line to assess theamount of blockage within a particular line or create positive pressureto aid in unblocking a particular line (from a pressure source 746).There may also be a pressure relief/release 747 within fluid managementsystem in situations where the sensed pressure within a line is above aset threshold value. Having pressure relief/release 747 may preventexcessive pressure being exerted on the patient's respiratory tract orwithin the fluid connections of either the respiratory insertion deviceor the fluid management system. The embodiment shown in FIG. 7 alsoincludes a collection jar 760. While the box diagram does not indicatethe possible number of collection jars, there can be one centralcollection where all of the extracted fluid can be retained or more thanone collection jar. In the case where there is only one collection jar,corresponding multi-port valves will be used to connect the fluid linesto the collection jar. A multiple collection jar set-up may be moreuseful for revealing where the source of an infection and providecaregivers with a clearer idea of what region along the patient'srespiratory tract to target treatment in case of infection. It may alsobe useful to include a volume sensor within all of the collection jarspresent such that when fluid with the jars reaches a certain level, afluid level sensor can signal the controller to sound an alarm to notifythe user that one or all of the collection jars require emptying.

A lavage system 750 is also present in the embodiment shown in FIG. 7 .Lavage system 750 includes a lavage pump 751 and a lavage pressurecontrol valve 752. Although not specifically shown here, lavage system750 may deliver a rinsing fluid 753 to at least one region alongrespiratory insertion device 770. Controller 701 regulates lavage pump751 and lavage pressure control valve 752 to deliver the rinse fluid ata desirable flow rate and pressure to the region or regions of interest.When the rinse portion of the lavage cycle is complete, lavage pump 751can exert negative pressure to suction away the rinse fluid. While notspecifically shown, an additional fluid line in connection with acollection jar can receive the post-rinse fluid. Alternatively, theadditional fluid line can connect to any of the fluid collection jarsalready present within the fluid management system. FIGS. 8 and 9 showtwo possible arrangements of the suctioning features in the fluidmanagement system embodiment discussed earlier. In FIG. 8 , a suctioningfeature is not included in fluid management system 800. In thisarrangement, the suctioning or vacuuming feature is provided forexternally. FIG. 9 shows the case where the suctioning/vacuuming isincluded within the fluid management system. While there are bothadvantages and disadvantages to both arrangements, neither greatlyaffect the overall functionality of the fluid management system.Finally, in both of the variations shown, the collection jars aresituated after the suctioning and pressure valves. The advantage ofhaving the suctioning and pressure valves in closer proximity to therespiratory insertion device is more precise control of the suctioningand pressure within the respiratory insertion device. The disadvantageof having the pressure and suctioning valves situated between therespiratory insertion device and the collection jar is that duringsuctioning, these valves may become more easily contaminated by thefluid passing through. Having the collection jar between the respiratoryinsertion device and the pressure and suctioning valves would minimizecontaminating the valves but also provide less precise control of thepressure and suctioning that occurs at the distal end of the respiratoryinsertion device.

FIG. 10 shows a more detailed diagram of an embodiment of the fluidmanagement system. While the system in FIG. 10 is similar to what isshown in FIGS. 7-9 , the diagram in FIG. 10 indicates more than ageneral concept of the fluid management system and discloses in greatdetail the components used to reduce the fluid management system topractice.

FIGS. 11-15 show further variation in the arrangement of the collectionjars and the various valves present within the fluid management system.In fluid management system 1100 shown in FIG. 11 , the collection jarsare placed before the suctioning and pressure valves. In system 1100,three separate lines emanate from respiratory insertion device 1170.Collection jar 1160 are associated with each line 1120. Collection jar1160 can be a single jar or multiple jars, for example, a collection jarcorresponding to each line. As previously mentioned, one of the mainadvantages of having the collection jars in front of at least some ofthe valves is that less contaminants reach those valves duringsuctioning, and requiring less frequent cleaning or replacement of thesevalves. There are also sensing units 1130, 1140 which sense pressure andflow and are associated with each fluid line. In many of theembodiments, filters are placed before the various modules to minimizecontamination of these modules. System 1100 also includes lavage 1150having three separate lavage lines 1153 that connect to the respiratoryinsertion device (not shown). The three lavage lines 1153 are controlledby a central lavage control valve 1152 and a lavage pump 1151. Alsoincluded is a lavage jars 1158 that contain lavage liquid where thelavage liquid can be pumped through to each of the lavage lines 1153 forrinsing out the different regions along the respiratory insertiondevice. It should be mentioned that the lavage control valve may onlyallow lavage liquid to pass to one or two of the lavage lines 1153 forrinsing. Control of which lavage lines receive rinsing fluid may becontrolled by the operator or may be based on a detected value orcondition set by the controller that then automatically signals thelavage system to activate. While not shown, lavage system 1150 mayinclude a separate line for removing lavage liquid once lavage iscompleted or may utilize fluid lines 1120 for collecting used lavageliquid, here the lavage liquid is returned to collection jar 1160.

FIG. 12 shows an alternative embodiment of the fluid management systemsetup. Similar to system 1100 setup, system 1200 has collection jars1260 are situated before suctioning valves 1245. One notable differencein system 1200 is the lavage lines 1253 feed into fluid lines 1220 andnot directly into the respiratory insertion device. As shown each lavageline 1253 taps into a corresponding fluid line 1220. In order to preventlavage fluid 1259 from traveling toward suctioning valves 1245 insteadof towards the respiratory insertion device during lavage, system 1200includes a series of non-return valves 1248. When on, non-return valves1248 forces lavage fluid toward the respiratory insertion device. Forexample, a non-return valve may have an on/off feature and may beoperated to close the suction line only after there is pressure due tothe lavage liquid; at other times the suction lines remain open.

FIG. 13 shows yet another embodiment of the fluid management systemsetup. Similar to system 1200, system 1300's lavage 1350 is routed tocorresponding fluid lines 1320 prior to reaching the trachea tube on thepatient. In system 1300, a collection jar 1360 is placed behindsuctioning valves 1345 and pressure valves 1344 are situated betweencollection jar 1360 and the respiratory insertion device. As previouslymentioned, one disadvantage of having fluid lines 1320 contactsuctioning valves 1345 and pressure valves 1344 is the greater chancefor contamination. In order to minimize this effect, valves will beconstructed having non-clogging components that will allow fluids ofdifferent density and viscosity to pass. In some examples, the interiorof the valves can be coated with non-adhering material making it moredifficult for microbes to attach. The valves can also be non-contactvalves (e.g., pinch valves) and thus solve the problem of contaminationas the valve body will never come in contact with the fluids and thevalves will only pinch the fluid lines 720 to shut them.

FIG. 14 shows a final fluid management system configuration having threefluid lines. In System 1400, jar 1460 is situated near the suctionsource and far away from suctioning valves 1445 and the respiratoryinsertion device. Suction valves 1445 are three way valves which allowdifferent functions of the fluid management system to share some of thesame lines which may decrease the space required within the fluidmanagement system. System 1400 includes lavage lines (not shown in FIG.14 ) that connect to rest of the fluid management components fluid lines1420 between suction valves 1445 and jar 1460. System 1400 also includesensor units 1430 and 1440 for monitoring pressure and flow. System 1400also includes additional suction control valves 1457 that may controlthe removal and flow rate of the used lavage liquid 1459 from therespiratory insertion device of the patient.

FIG. 15A shows a fluid management system embodiment having fourindependent fluid lines. The remainder of the fluid management systemremain the same. In this embodiment, the extra fluid line can be used toremove fluid from a fourth location along the tracheal tube. Also, theadditional fluid line may be used to remove fluid from within the actualtracheal tube as well.

FIG. 15B illustrates an example of a fluid management system such asthose described above. In FIG. 15B, the controller 1561 may be housedwithin a controller housing, and connected to a source of suction (e.g.,suction line 1563) or may include an internal pump (not shown) forproducing positive and/or negative pressure. The controller may includea plurality of ports 1567, 1567′, 1567″ for connecting to the lines,e.g., from a respiratory insertion device. Alternatively, some or all ofthese lines may be extensions that are integrated with the controller(e.g., permanently or removably attached thereto). The system mayinclude connectors (C4, C3, C2, C1) to connect to couplers on arespiratory insertion device (which may include an endotracheal device).The controller may also include a separate or integrated lavage unit1550 that may be configured to provide, via positive pressure through afluid line in the respiratory insertion device, a source of lavage fluid(e.g., chlorohexidine). The positive pressure may be from an internalpump 1571 or from an external pressure source.

The controller may also include controller circuitry 1581 that isconfigured to include any combination of hardware, software and/orfirmware to perform the functions for any of the apparatuses asdescribed herein. In FIG. 15B, the controller circuitry is shown in abox spanning the lavage unit and the suction unit. This is because thiscontrol circuitry may communicate (and control) any of the components ofthese units (sub-units). The controller circuity may be configured toinitialize the apparatus, including setting the baseline pressure, toconfirm that the respiratory insertion device (e.g., an endotrachealtube) is connected to the system, may automatically and periodically (ormay allow manual triggering) the application of lavage fluid and/or theremoval of fluid from in and/or around the respiratory insertion device,and/or may determine if one or more of the fluid lines is clogged,and/or may clear a detected clog (and if not cleared, may issue analert). Finally the controller circuity may be configured to communicatewith the user and/or a remote server.

The controller may also include an integrated set of one or morecollection jars, or may separately connect to one or more collectionjars; in FIG. 15B, three separate collection jars (each configured toconnect to a separate fluid line, e.g., oral line, oropharyngeal lineand subglottic line, are connected in-line with the controller and thepatient, between the controller housing a separate sensor unit 1575.Thus, the controller may communicate with a separate flow sensor unit1575. In FIGS. 15A and 15B the sensing unit may be a separate housingthat is independently positionable on the fluid lines of the respiratoryinsertion device. The sensing unit housing a plurality of non-contractflow sensing sensors (SSL, SSO, SSP, SSS), each adapted to sense flow ina separate one of the lavage lines (e.g., upper oral cavity), oral line(lower oral cavity), oropharyngeal line, and subglottic line; this mayallow the flow sensors to be positioned closer to the patient 1681 thanthe controller unit (e.g., within a few feet of the patient's mouth,e.g., within 3 feet, within 2 feet, within 1.5 feet, within 1 feet,etc.). In FIG. 15A, similar to what is shown in FIG. 31A, the fluidlines comprise lumen arising from a combined respiratory insertiondevice that may be applied over an endotracheal tube connected to thepatient, an integrated endotracheal tube, or any combination of these.

FIGS. 16A-16C shows pictorials of a fluid management system setupreduced to practice. FIG. 16A shows the controller in connection withvarious fluid lines. FIGS. 16B and 16C shows close-ups of the controllerwhich includes valves, pump, motor, and micro-controls.

FIG. 31A illustrates another example of a fluid management systemincluding many of the features of the systems described in FIGS. 2-16C.In FIG. 31A, the system generally includes a controller 3103 that ishoused in a housing 3105 enclosing the controller circuitry, but alsoincludes one or more inputs (shown as buttons 3107) on the outside ofthe housing, along with an output (shown as a screen 3109). Thecontroller also includes a plurality of ports 3111-3111′″ that areconfigured to connect to coupler of a respiratory insertion device. InFIG. 31A, an exemplary respiratory insertion device 3119 is shown. Thisrespiratory insertion device may be applied over an endotracheal tube3121 either before or after it has already been inserted into a patient.As described above, the system may also include one or more optical flowsensors. In FIG. 31A, the optical flow sensors are included in aseparate housing 3117. This housing is configured so that the fluidlines of the respiratory insertion device may be enclosed within thehousing. For example, the flow sensor housing may include a two-parthousing that is configured to close over the fluid lines of therespiratory insertion device. The housing may include a hinged door.Thus, the smaller optical flow sensor housing may be attached, withoutrequiring additional support, to the respiratory insertion device verynear the patient. The optical sensors may communicate information to thecontroller directly, either via a wired connection, or a wirelessconnection.

Typically the controller circuitry within the controller may beconfigured as described above, to monitor for fluid within the patientaround then endotracheal tube, and/or to remove fluid. The controller(e.g., the controller circuitry) may also be configured to detect whenthe controller is connected to a respiratory insertion device (includingdetecting when the respiratory insertion device is inserted into apatient), and/or detecting when any of the lines of the respiratoryinsertion device are clogged. As already described above, in general,the controller may use a combination of the pressure sensor(s) connectedto the ports (therefore configured to detect pressure in each of theconnected fluid lines of the respiratory insertion device) as well asusing the flow sensors, in order to determine when a line is clogged,and/or connected, and/or still removing fluid from the patient. Thecontroller may also include or be coupled to one or more collectioncontainers for collecting fluid removed from the patient. In addition,the controller may include a source of lavage fluid and may apply thelavage fluid through, e.g., the upper oral cavity fluid lines of therespiratory insertion device.

In FIG. 31A, the system for automatically removing fluid from multipleregions of a respiratory tract and lavaging an oral cavity portion ofthe respiratory tract includes the controller and the plurality ofoptical flow sensors. The controller 3105 may contain the controllercircuitry, a first pressure sensor, a second pressure sensor, a thirdpressure sensor, a first port in communication with the first pressuresensor and configured to connect to a first fluid line, a second port incommunication with the second pressure sensor and configured to connectto a second fluid line, a third port in communication with the thirdpressure sensor configured to connect to a third fluid line, and one ormore valves configured to couple to a source of air pressure. Theoptical flow sensors 3117 may include, for example, a first optical flowsensor configured to couple to an outside of a first fluid line todetect flow within the first fluid line, a second optical flow sensorconfigured to couple to a second fluid line to detect flow within thesecond fluid line, a third optical flow sensor configured to couple to athird fluid line to detect flow within the third fluid line, wherein thefirst second and third optical sensors are housed separately from thecontroller. As described above in FIGS. 2-16 , the control circuity maybe configured to detect when fluid lines are connected to each of thefirst, second and third ports. For example, the controller circuitry maydetect when a line is connected by determining that there is aresistance to negative or positive pressure at the ports (e.g., upperoral port 3111′″, oral port 3111″, oropharyngeal port 3111′ andsubglottal port 3111). For example, if no line is connected, theresistance to pressure applied with be negligible. The system mayperiodically apply negative pressure to each of the first, second andthird ports when fluid lines are detected (either at the same time orseparately), and to stop applying negative pressure on the first portwhen the first optical flow sensor indicates there is no more flow, tostop applying negative pressure on the second port when the secondoptical flow sensor indicates there is no more flow, and to stopapplying negative pressure on the third port when the third optical flowsensor indicates there is no more flow. The controller circuitry mayalso detect a blockage in the first fluid line based on the firstpressure sensor and the first optical flow sensor. For example, bydetecting a high resistance to pressure (negative or positive) at theport when there is no flow. If a particular line is unblocked, theresistance to flow will be relatively low, with little flow detected.During removal of fluid, a fluid flow may be detected, with someresistance to flow. The controller circuitry may also be configured todetect a blockage in the second fluid line based on the second pressuresensor and the second optical flow sensor, and to detect a blockage inthe third fluid line based on the third pressure sensor and the thirdoptical flow sensor. The controller circuitry may also be configured toclear a detected blockage by applying a high suction (negative pressure)and monitoring for flow and/or resistance to pressure. Clearance of ablockage will typically result in the system detecting an increase inflow and/or a decrease in resistance to pressure.

In general, the flow sensors may be optical sensors, such as infrared(IR) based flow sensors. The controller circuity may tune and/orcalibrate the sensors. For example, the controller may, during aninitial set-up period, calibrate the sensors by doing one or more samplesuctions.

The controller circuitry may detect blockage in one or more lines asmentioned above. Typically, if there is a blockage, the pressuredetected on the blocked line (which may be referred to herein as theresistance of the line when applying positive or negative pressure)raises to the about the same level as if that line were closed. Forexample, if the controller circuity is set to apply X pressure to aline, if there is no block on the line there will likely be flow in theline, and the sensed pressure (resistance in the line) will typically beless than X. If, during a pressure applying cycle, the pressure in theline is sensed to be close to X, there must be a blockage; the lack offlow (or very slow flow) may confirm this. Thus, low flow with highpressure (within about 80% of applied pressure), may indicate ablockage. The use of optical flow sensing may toggle detection ofblockage. For example the system may be configured to look at pressurewhen (or only when) there is no flow through the line. The combinationof both optical sensor and pressure sensors to identify blockage makes asurprisingly robust system.

As mentioned above, blockage may be cleared by, for example, applying anincreased pressure for a predetermined amount of time (e.g., increasingthe pressure for 5 seconds), then reducing or stopping the appliedpressure. If this does not work to restore flow and/or reduce pressure(resistance to pressure, so that the pressure in the line is less thanthe applied pressure in the line, e.g., <60%, 65%, 70%, 75%, 80%, 85%,90%, 95%, etc., of the applied pressure) in the line, the system maytrigger an alarm for manual intervention, e.g., by a caregiver.

In any of the systems described herein, the systems may automaticallyconfirm correct connections of suction lines. For example, thecontroller circuitry may be configured to do a leakage test. Forexample, the system may be configured to do a leakage test upon turningthe apparatus on, at startup and/or periodically through the operationof the device, between fluid removal periods. If there is any leakage,then the system may conclude that the tubing is not connected, and mayprovide an alert message to this effect. For example, the system may beconfigured to apply suction (negative pressure) to any of the ports,separately or simultaneously, and to monitor the pressure at each port(e.g., within each line, if a line is connected). From this, the systemmay compare the applied pressure to the sensed pressure. If a line isnot connected, there will be substantially no resistance to appliedpressure at the port, and the system will see a drop in the sensedpressure to zero (from a negative pressure or a positive pressure),indicating a leak or non-connection of the line. In this case, thesystem may also confirm that there is no flow detected by the flowsensor(s). The system may provide a notification or alert that there isa leak and/or that the corresponding port/line is not connected or notproperly connected.

As mentioned, the systems described herein may be configured tocalibrate the sensors at the start of use, and/or periodically duringuse. For example, when turning the system on initially, the system(e.g., the controller circuitry) may operate the system to initiallycalibrate. For example, any of the systems may be configured tocalibrate the automatic detection of atmospheric pressure when initiallystarting up. The atmospheric pressure may be different at differentlocations where the system may be operated. For example, at differentaltitudes the baseline for pressure values may be different. Sincebaseline “air pressure” may be used by the controller circuitry todetermine when the apparatus is connected and/or clogged (e.g.,comparing detected pressure in any of the ports and therefore connectedlines to various thresholds), the system may determine atmosphericpressure at the initialization of the system to get an estimate forbaseline (0) pressure. The automatic detection of atmospheric pressure,and adjustment of a system baseline pressure based on the automaticdetection of atmospheric pressure may also provide for optimal operationof the pressure and sensors, regardless of variations in atmosphericpressure.

In any of the apparatuses described herein, the controller may include aplurality of microcontrollers. For example, the system may include oneor more microcontroller to control the pressure sensors and/or one ormore microcontrollers to control the optical flow sensor(s) in theseparate housing. A microcontroller may be used to control theproportional flow (e.g., pressure). A separate or the samemicrocontroller may operate as a master controller to control valves andinputs/outputs to control the display. For example, in some variationsthree or more microcontrollers may be used to handle different functionsand the operation of these microcontrollers may be coordinated to handledifferent functions. The use of separate microcontrollers may enhancesystem stability and may allow parallel operations, and constantvalidation of pressure through multiple sensors.

In general, any of the systems described herein may be configured tooperate on two or more (e.g., 3, 4 or 5) regions, including upper oral(e.g., for the application of lavage fluid), lower oral (e.g., removalof fluid and secretions), oropharyngeal (e.g., removal of fluids and/orsecretions), and subglottic regions (e.g., removal of fluids and/orsecretions). The removal of fluid and secretions from these regions(e.g., the oral and oropharyngeal suctioning in particular) may reducethe flow to the subglottic region and can reduce the chance ofinfection. Any of these apparatuses may be configured to provide forautomated suction cycles across 2 or more (e.g., 3, 4, or 5 ports). Thisautomatic suctioning may reduce the workload of a caregiver, as manualsuctioning is not required from other areas of the patient.

The system may manage the suction cycles based on the data from the flowand/or pressure sensors. As discussed, the system may stop theapplication of suction when it detects that there are no additionalsecretions in a particular line, which may help avoid or reduce tissuedamage that may otherwise occur if applying excess suction. Theautomated port block detection and clearance enhances the efficiency ofthe system in reducing infection. In general, port blockage is asubstantial reason for failure of existing secretion management systems.The automatic confirmation of correct connections of suction lines,which may be achieved through the use of optical flow sensors and/orpressure sensors as described herein may protect the system. The systemmay be configured to prevent stating unless the lines are connectedcorrectly, minimizing the possibility of incorrect usage and enhancingpatient safety. In addition, the automated calibration of the flowand/or pressure sensors and detection of leakage in the system beforeinitiation may greatly enhance performance. Leak detection may ensurethat a patient is not sub-optimally treated when there is an undetectedleak.

FIG. 31B illustrates another example of a fluid management system 3151including 2-16C, above. In FIG. 31A, the system includes a controllerthat is housed in a housing 3155 enclosing the controller circuitry, butalso includes one or more inputs (shown as buttons) on the outside ofthe housing, along with an output (shown as a screen). The controlleralso includes a plurality of ports 3111-3111′″ that are configured toconnect via individual lines (fluid lines, forming part of the “tubingkit” 3161) to a coupler of a respiratory insertion device 5157. In FIG.31B, the exemplary respiratory insertion device 5157 is shown insertedinto the patient's mouth connected to an inserted tracheal tube 5158.Thus, the respiratory insertion device may be applied over anendotracheal tube 3158 either before or after it has already beeninserted into a patient. As described above, the system may also includeone or more optical flow sensors 3163; the flow sensors may be housed ina separate housing, as shown. This housing is configured so that thefluid lines of the respiratory insertion device may be enclosed withinthe housing. For example, the flow sensor housing may include a two-parthousing that is configured to close over the fluid lines of therespiratory insertion device. The optical sensors may communicateinformation to the controller directly, either via a wired connection,or a wireless connection. The example systems shown in FIGS. 31A and 31Bmay be similar to the variation shown in FIG. 15B.

In general, any of the systems described herein may include an inbuiltmechanism using a pressure sensor, compressor/pump and a connection toan endotracheal cuff (or other cuff connected to a respiratory insertiondevice, including an endotracheal tube) to measure and maintain cuffpressure in the endotracheal tube. Thus, any of these systems mayinclude connection to an inflation line and/or pressure sensors and/orpump and the controller circuitry may be configured to monitor andcontrol the inflation of the cuff.

Any of the systems described herein may also include a dedicated suctionport to connect to a closed suction catheter and provide on demandsuctioning at a pressure set by the user. In general, the user may alsoor additionally manually select and apply suction on any of the fluidlines connected to the apparatus.

Respiratory Insertion Devices

As mentioned, the fluid management systems described above may becoupled to a respiratory insertion device. FIGS. 17-30 describe therespiratory insertion device connected to the fluid management system aswell as different embodiments of the respiratory insertion deviceenvisioned.

In some variations, a respiratory insertion device will snap over anyendotracheal tube and can be slid down into the appropriate position.For example, the sheath/sleeve may be placed in the oral cavity of anintubated patient with the dorsal end reaching till the vocal chords.The sheath/sleeve may have two or more (e.g., three) parallelindependent channels running with multiple openings/ports at differentlocations corresponding to the subglottic region, oropharyngeal regionand the oral cavity. In some variations the sheath includes only twolumen (channels) as the tracheal tube onto which it is connected alreadyhas a lumen that may be used to remove fluid from a region around(and/or within) the tracheal tube. The ends of these channels havingconnectors for coupling with suction line tubing.

The respiratory insertion device can be constructed of any suitablematerials. Such materials include but are not limited to: polyurethane,polyvinyl chloride (PVC), polyethylene terephthalate (PETP), low-densitypolyethylene (LDPE), polypropylene, silicone, neoprene,polytetrafluoroethylene (PTFE), or poly-isoprene or any other relevantelastomer, plastic, or rubber or any other bio-compatible material.

The respiratory insertion device may be connected to connecting tubing,and the sensing unit(s) may be placed for optimum sensing. The sensingunit contains fluid detection sensors and sends its values to a controland processing unit which has a microcontroller, and a set of valvesnamely, suction shut on/off valve, lavage shut on/off valve, suctionpressure control valve, lavage pressure control valve. It also housesthe variable output pump, collection jar and display. The collection jarhas a provision to attach a sample collection system which includes butnot limited to the small jar, for collection of small amount ofsecretions to be sent to the microbiology/pathology lab.

The control and processing unit is driven by an external or internalpower supply. It takes the suction from an external negative pressuresource such as any suction creating apparatus (wall mounted suctionline, portable suction system, independent suction system) and isconnected to the control unit.

FIG. 17 shows the global tracheal management system which includes afluid management system 1700 and a respiratory insertion device 1770. Ingeneral respiratory insertion device 1770 includes a sheath 1773 havinga proximal end 1771 and a distal end 1772. Proximal end 1771 is situatedadjacent to fluid management system 1700. Distal end 1772 corresponds tothe subglottic region of an intubated patient. Respiratory insertiondevice 1770 generally includes at least two lumen and typicallycomprises a third. In FIG. 17 , three lumen 1774, 1776, and 1775 areshown. The proximal and distal end of each of lumen 1774, 1776, and 1775extend longitudinally along the length of sheath 1773. Each of theproximal end of lumen 1774, 1776, and 1775 can couple to correspondingfluid lines (not shown) of fluid management system 1600. Distal ends oflumen 1774, 1776, and 1775 corresponds to different regions along atracheal tube. In particular, the oral cavity, the oropharynx, and thesubglottic regions on an intubated patient are of interest. Distal endof lumen 1774, 1776, and 1775 each include oral suctioning ports 1777,1778, and 1779 for detection and withdrawal of fluid from these regionsin direct contact with the ports. Further shown in FIG. 17 are flowsensors 1730 and liquids/pressure sensors 1740. Flow sensors 1730 candetect the flow rate of fluid with the fluid lines and aid in theregulation of flow within the fluid lines. Pressure sensors 1740 candetect the amount of resistance when negative pressure is appliedthrough the fluid lines and relay to the controller if the amount ofresistance is greater than a threshold value, indicating that there isblockage in the line. While pressure sensors 1740 shown in FIG. 17 arelocated on lumen 1774, 1776, and 1775, the pressure sensors can beplaced on the fluid line and external to the respiratory insertiondevice.

Different combinations of the respiration insertion device can becoupled to the various configurations of the fluid management systemdiscussed above. FIG. 18 shows a subset of possible combinations ofrespiratory insertion device with the fluid management system. First ofall, the fluid management system can be used with a traditional trachealtube, more specifically an endotracheal tube or a tracheostomy tube.This may not be ideal because traditional tracheal tube do not possessthe necessary lumen and corresponding ports that would allow monitoringand evacuation of fluid. FIG. 18 also shows that the fluid managementsystem can be used with a modified tracheal tube having lumen thatattach to an existing tracheal tube. FIG. 18 also shows a continuousaspiration of subglottic secretion (CASS) tube which allow forsuctioning along the subglottic regions as well as use with innovativeintegrated tracheal tube configurations that will also be morethoroughly discussed in the following paragraphs. And finally, thediagram indicates that the fluid management system can also work with anintegrated endotracheal tube where the lumen are integrated into thedevice body.

FIGS. 19A-19D show a first embodiment of a respiratory insertion device1970. Respiratory insertion device 1970 has a proximal end 1971 that isnear the mouth of the intubated patient and a distal end 1972 thatcorresponds to the end of the patient's trachea and the top of thebronchi region. Respiratory insertion device 1970 has a spiralconfiguration where a device body 1973 winds around an existing trachealtube 1990. Device 1970 is prevented from pushing past a safe region ofthe patient's respiratory tract once the distal end of device 1970 abutsa cuff 1991 of the tracheal tube and proper positioning of device 1970along the existing tracheal tube is achieved when the distal end ofdevice 1970 sits against cuff 1991 and the proximal end of device 1970adjoins the proximal end of the existing tracheal tube. Device 1970includes at least one device fluid line 1980 for suctioning. Devicefluid line 1980 may include a coupler 1981 for attaching to the fluidlines of the fluid management system. The small circles along thetracheal tube show where fluid is most likely to accumulate. As priorreferences have indicated, one area of fluid accumulation corresponds tothe subglottic region of the patient especially around the cuff. Othertwo regions not specifically mentioned and targeted by earlier trachealtube fluid management devices are the oral cavity and the oropharyngealregions adjacent to the tracheal tube. An unconscious intubated patientcannot tell that saliva is pooling in their mouth and has no automaticreflex to rid his or her mouth of the fluid especially with the presenceof the tracheal tube. The oropharyngeal region is also susceptible tofluid accumulation due to the arcuate bend in the tracheal tube as itpasses the oral cavity into the trachea in combination with the typicalhorizontal position of an intubated patient. FIG. 19A shows arespiratory insertion device similar to that in FIG. 17 ; FIGS. 19B,19C, and 19D show enlarged views of portions of this device. Suctioningports are disposed at various regions on the device body 1973. A blow-upview that corresponds to the oropharyngeal region along the trachealtube shows a plurality of ports 1978. The circles and arrows show thefluid and other debris moving toward ports 1978 to be suctioned away.While not specifically shown, ports are also disposed on the respiratoryinsertion device body that corresponds to the oral cavity and thesubglottic region of the intubated patient. Also, the spacing of theports corresponding to different regions of the tracheal tube should beat least 0.4 inches from each other (e.g., the ports at the distal endsof the lumen). At the proximal ends of the lumen, which may connect tofluid lines, ports into the lumen may be immediately adjacent to eachother or may extend as tubes from the device. This requirement does notapply to ports associated with the same region, which is shown in theenlarged views in FIGS. 19B, 19C, and 19D.

FIG. 20 illustrates aspects of a respiratory insertion device 2070 forremoving fluid from two or more regions along a tracheal tube inaccordance with some embodiments. Device 2070 includes a sheath 2073.Sheath 2073 having a hinge 2084 and an opening 2085. Disposed along theperimeter of sheath 2073 are a plurality of lumen. In FIG. 20 , twolumen 2074 and 2075 are shown. Lumen 2074 and 2075, when connected tofluid lines of the fluid management system, are able to suction twodifferent locations of an existing tracheal tube through ports (notshown) disposed adjacent to the distal end 2072 of device 2070. In use,hinge 2084 of sheath 2073 can open and increase the circumference ofopening 2085. A user can then more easily slide device 2070 over anexisting tracheal tube either prior to placing the tracheal tube in apatient or after placement of the tracheal tube. Couplers 2081 are alsopresent for connecting to the fluid management system. In variations ofthis embodiment, more than two lumen are disposed along the perimeter ofthe device sheath.

FIG. 21 illustrates aspects of a respiratory insertion device 2170 forremoving fluid from two or more regions along a tracheal tube inaccordance with some embodiments. Device 2170 includes one or moresleeve 2173. Sleeve 2173 function much like a stent wherein sleeve 2173expands laterally when a force is longitudinally applied and thus device2170 can be segmentally inserted over an existing tracheal tube. Device2170 may include lumens along the perimeter of the top sleeve thatextend along the longitudinal axis of the top sleeve. The top sleeve mayinclude a lumen that terminates at a top sleeve port opening forsuctioning a first region along the existing tracheal tube. The firstregion may correspond to the oral cavity of the intubated patient. Lumen2174, 2175, and 2176 are shown entering the sleeve 2173 at a ring 2182.The top sleeve can align and couple to lower sleeves havingcorresponding lumen that terminate at port openings along the length ofthe lower sleeve. A first port opening 2177 may correspond to the oralcavity of a patient. Other port openings 2178 and 2179 may correspond toa second and a third region along the existing tracheal tube such as theoropharyngeal and subglottic regions. While the lumen in FIG. 21 are allshown to insert at largely one point onto the sleeve, it is alsopossible for the different lumen to insert at different points on thering and having corresponding channels in the lower sleeves. Also, eachlumen include couplers 2181 for attaching to the fluid management systemor the like. It should be note that in positioning this deviceembodiment, ventilation may have to be disrupted for a short period toenable fitting of the sleeve over the existing tracheal tube.

FIGS. 22A-22C illustrate aspects of a respiratory insertion device 2270for removing fluid from two or more regions along a tracheal tube inaccordance with some embodiments. Device 2270 is designed to fit over anexisting tracheal tube and includes a series of stacked rings 2282 heldtogether by a series of support structures 2273. Stacked rings 2282 mayinclude at least one set of longitudinally-aligned ring apertures.Device 2270 further include an integrated lumen 2281 that is able toreach various points along the length of the existing tracheal tube. Thedistal end of the integrated lumen 2281 includes a series oftentacle-like lumen that thread through at least one of thelongitudinally-aligned ring apertures 2288. The tentacle-like lumen atthe distal end that are able to reach farther along the existingtracheal tube may thread through two or more of thelongitudinally-aligned ring apertures 2288. The tentacle-like lumen2274, 2275, and 2276 terminate with corresponding suctioning ports 2277,2278, and 2279 that are able to remove fluid from the correspondingregions along the existing tracheal tube. Finally, the lumen cometogether at the proximal end of the integrated lumen 2281 and couple toa connector 2281 that links the lumen to the fluid management system.

FIGS. 23A-23B illustrate aspects of a respiratory insertion device 2370for removing fluid from two or more regions along a tracheal tube inaccordance with some embodiments. Device 2370 is able to attach to anexisting tracheal tube. Device 2370 includes a device body 2373 alongone side and a series of clips 2383 that enables device 2370 to attachto the existing tracheal tube. Series of clips 2383 each include anopening 2385 that allows a user to slightly increase the diameter of theseries of clips 2383 for fitting device 2370 over the existing trachealtube. Device 2370 includes a cavity 2386 that runs essentially theentire length of device 2370. While not shown, catheter or tubing can beinserted through cavity 2386 to terminate at various points along device2370 for suctioning at different regions along the tracheal tube.

An alternative embodiment to device 2370 is a device 2470 as shown inFIGS. 24A-24B. One difference between device 2470 and 2370 is thatdevice 2470 is composed of two different materials. The majority ofdevice 2470 is composed of a softer elastomer that is flexible along thelongitudinal axis of the device. Device 2470 includes regions having “C”shaped-supports 2487 comprising stiffer material. The C-shaped supports2487 are situated along the longitudinal axis of device 2470 providesoverall rigidity in the transverse plane of device 2470. Device 2470includes a channel 2486 that runs along and follows the curve of thedevice body. Channel 2486 may retain at least one catheter or tubingbody for suctioning at least one area along the existing tracheal tube.Where there are greater than one catheter or tubing body held withinchannel 2486, the distal ends of the catheter or tubing body terminatesat different points along the existing tracheal tube.

Next, FIGS. 25A-25C illustrate aspects of a respiratory insertion device2570 for removing fluid from two or more regions along a tracheal tubein accordance with some embodiments. Device 2570 is a variation on theclip format. Device 2570 has a proximal end 2571, a distal end 2572, anda device body 2573. Proximal end 2571 is situated near a patient'smouth, while distal end 2572 is located between the lower trachea andbronchi of a patient. FIG. 25A shows a close-up of proximal end 2571which includes a series of channels 2586 that follow the length ofdevice body 2573 and terminate at various points along an existingtracheal tube. In some examples, channels 2586 correspond to the oral,oropharyngeal, and subglottic regions on a patient. FIGS. 25B and 25Cshow that some of the channels 2586 terminate at three ports 2574, 2575,and 2576 for suctioning different regions along the existing trachealtube. Depending on how fluid lines are attached, some of the channelscan be used for lavage of various regions of the patient's oral,oropharyngeal, and subglottic cavities. Finally, device 2570 includes anopening 2585 that allows for easier placement of device 2570 over atracheal tube.

FIGS. 26A-26C shows a variation of the device shown in FIGS. 25A-25C.Similarly, device 2670 has a clip-on format that allows it to attach toan existing tracheal tube. Device 2670 includes a device body 2673, aproximal end 2671, and a distal end 2672. Device 2670 also has aC-shaped cross section having an opening 2685, where the distance of theopening is greater than that for device 2570. At proximal end 2671 ofdevice 2670 includes two couplers 2681 that allows device 2670 toconnect to a suctioning system such as the fluid management systemdescribed earlier. Couplers 2681 attach to channels 2674 and 2675 thatrun along the length of device 2670 and terminates at different zonesalong device 2670. At the terminus of channels 2674 and 2675 are ports2674 and 2675 for suctioning different regions along an existingtracheal tube.

FIGS. 27A-27D illustrate aspects of a respiratory insertion device 2770for removing fluid from two or more regions along a tracheal tube inaccordance with some embodiments. Device 2770 is another version of aclip-on fluid suctioning device that can be mated with an existingtracheal tube. Device 2770 has a device body 2773, a proximal end 2771that is close to a patient's oral cavity when in use, and a distal end2772 that is between the patient's lower trachea and bronchi when inuse. Device 2770 includes a series of clips 2783 for coupling to atracheal tube. Device 2770 also includes stacked lumen 2774, 2775, and2776 that run the length of device body 2773 and terminate at differentregions along device body 2773. At the terminus of lumen 2774, 2775, and2776 are corresponding ports 2777, 2778, and 2779 for working with thefluid management systems described above or other like systems to detectand suction fluid from different regions along the tracheal tube. Whilenot shown, proximal end of lumen 2774, 2775, and 2776 can be coupled tofluid lines of the fluid management system or other like systems.

FIGS. 28A-28G illustrate aspects of a respiratory insertion device 2870for removing fluid from two or more regions along a tracheal tube inaccordance with some embodiments. Device 2870 is an integrated trachealtube having sensing and suctioning capabilities as well as an airwaypassage for connecting to an external breathing mechanism. Device 2870includes a device body 2873, a proximal end 2871, and a distal end 2872.A cuff 2891 is located towards distal end 2872 of device 2870. Device2870 further includes a tracheal tube portion 2890, a cuff inflationline 2892, and a first, second, and third lumen 2874, 2875, 2876 forsuctioning different regions along the respiratory tract of a patient.The distal ends of lumen 2874, 2875, and 2876 all terminate withcorresponding ports 2877, 2878, and 2879 that aid in sensing andremoving fluid from different points along device body 2873. FIG. 28Gshows a cross-section of this particular embodiment of respirationinsertion device 2870 where respiration insertion device 2870 furtherincludes an internal port 2893 for suctioning in internal region of thetracheal tube portion of respiration insertion device 2870. Also visibleare the channels associated with ports 2877 and 2878 which correspond tothe oral cavity and the oropharyngeal cavity regions.

Turning to FIGS. 29A-30 , devices for use in a tracheostomy scenariowill be described. FIGS. 29A and 29B show a first embodiment of atracheostomy device 2970. Device 2970 includes a proximal end with oneor more (e.g., three in this example) fluid line connectors 2971, 2971′,2971″, a distal end 2972, and a device body 2973. Device body 2973 isbifurcated into a first and second lumen, 2974 and 2976. In use, firstlumen 2974 is located outside of the tracheostomy tube while secondlumen 2976 is largely situated within the tracheostomy tube as shown inFIG. 29B. First lumen 2974 includes a first port 2977 at its terminusthat is used for detecting and removing fluid from a first externalsurface of the tracheostomy tube, primarily above an inflatable cuff2991 of the tracheostomy tube. Second lumen 2976 is longer than firstlumen 2974 and includes a bend at its terminus. At the bend, secondlumen 2976 exits the tracheostomy tube and terminates below cuff 2991.At its terminus, second lumen 2976 includes a second port 2979 forsensing and suctioning a lower region of the tracheostomy tube justbelow cuff 2991. Second lumen 2976 also includes a third port 2978 thatis situated within and near the distal end of tracheostomy tube forsensing and removing fluid from the lower portion of the tracheostomytube. Finally, device 2970 includes a coupler 2981 for attaching to thefluid management or like system for sensing and removing fluid fromdifferent regions along the tracheostomy tube.

A second embodiment of a tracheostomy device 3070 is shown in FIG. 30 .Device 3070 is an integrated tracheostomy tube and a fluid sensing andmanagement device. Device 3070 includes three independent lumen 3074,3075, and 3076 that is integrated with a tracheostomy tube 3073. Theproximal ends of lumen 3074, 3075, and 3076 include couplers 3081 forconnecting to the fluid management or other like systems. The terminusof each lumen 3074, 3075, and 3076 are at different locations alongtracheostomy tube 3073. At the terminus of each lumen 3074, 3075, and3076 are corresponding ports 3077, 3078, and 3079 for sensing andremoving fluid from their corresponding regions. In some instances,fluid, such as a lavage fluid 3050 can be introduced into the interiorof tracheostomy tube 3073 and the rinse fluid can be removed via ports3077, 3078, and 3079.

FIGS. 32A-36G illustrate another example of a respiratory insertiondevice similar to those described above in FIGS. 19A-27C and 29A-29B. InFIG. 32A, the respiratory insertion device is configured for use with anendotracheal tube to independently remove fluid from multiple regions ofa respiratory tract. When used with a system for automatically removingfluid from multiple regions of a respiratory tract, as described above,the controller of the system may connect directly to the lines (fluidlines) forming lumen for the application and/or removal of material fromin and/or around an existing endotracheal tube. The system forautomatically removing fluid from multiple regions of a respiratorytract may also connect to one or more fluid lines of the endotrachealtube, as well as to the one or more lines of the respiratory insertiondevice, as shown in FIG. 31A (showing the respiratory insertion deviceof FIG. 32A connected to the upper oral port 3111′, oral port 3111″, andoropharyngeal port 3111′ of the respiratory insertion device, and alsoconnected to the endotracheal tube's subglottal line via the subglottalport 3111). The same controller may monitor and regulate all of theseports, or a subset of them.

For example in FIG. 32A, the respiratory insertion device is configuredto connect securely to an endotracheal tube that is already insertedinto a patient's oral cavity. The respiratory insertion device includesa sheath body 3203 (similar to that shown in FIG. 20 , above) thatsecures the respiratory insertion device 3201 to an endotracheal tube.The sheath body may also align the respiratory insertion device with theendotracheal tube and the patient's body when inserting it. For example,the sheath body 3203 may include a longitudinal channel 3205 with alateral opening 3207 extending proximally to distally wherein thelongitudinal channel is configured to fit over the endotracheal tube.The respiratory insertion device also includes an extension 3209extending distally from a distal end of the sheath body. This extensionmay curve in the distal-to-proximal axis, as shown in FIG. 32A and sideview of FIG. 32F. The extension region 3209 may be flatter and thinnerthan the sheath body, which may allow it to be somewhat softer as well.

In FIG. 32A, the sheath body region may also include one or more biteflanges 3213 extending proud (e.g., at an approximately 90 degree angle)relative to the distal-to-proximal axis of the sheath body. The biteflange may be formed integrally with the sheath body or it may be aseparate region. In some variations, the bite flange is formed of aharder material than the majority of the respiratory insertion device,including the extension region 3209 and/or the channel region of thesheath body. The bite flange may be used to align the respiratoryinsertion device when inserting into a patient's mouth over anendotracheal tube by pushing the apparatus over the insertedendotracheal tube until the flange contacts the patient's teeth. Thismay limit the insertion of the respiratory insertion device, and mayalso align the ports of the respiratory insertion device so that theyare positioned in the patient's upper oral region (e.g., for delivery ofa lavage fluid), the lower oral region (for suctioning) and theoropharyngeal region (for suctioning).

The respiratory insertion device also typically includes a plurality oflumen that may correspond to a tubing (e.g., a flexible tubing) that maybe held by the sheath body or may be continuous with a lumen formedin/through the sheath body. For example, in FIG. 32A, three pairs ofparallel tubing sets correspond to the upper oral 3221, lower oral 3223,and oropharyngeal 3225 lumen. Each of these pairs combines at theproximal end into a proximal coupler 3222, 3224, 3226. For example, inFIG. 32A, a first lumen continuous with a tube 3221 passes through thesheath proximally to distally and extends between a first proximalcoupler 3222 and a first distal opening 3231 that is adjacent to thedistal end of the sheath body. The first distal opening 3231 may beconfigured to spray, e.g., a mist, of lavage solution into the oralcavity. Similarly, a second lumen continuous with the lumen of anothertube 3225 passes through the sheath proximally to distally and extendsbetween a second proximal coupler 3226 and a second distal opening 3235that is at a distal end region of the extension 3209. In this example,this second lumen has two distal end openings 3235, 3235′, both formingoropharyngeal suction ports, for removal of material from around theoropharyngeal region of and endotracheal tube. A second pair of distalend openings, 3235″, 3235″, corresponding to the parallel lumen, may bepresent on the opposite leg/foot region 3255′. These openings are formedas continuous lumen through foot or leg regions 3255 of the extensionportion of the device. Similarly, a third lumen continuous with lumen ofa tube 3223′ may pass through the sheath proximally to distally, andextend between a third proximal coupler 3224 and a third distal opening3233 that is between the first distal opening 3231 and the second distalopening 3235. The opening 3233′ in this example is protected by a flattongue-protecting region 3274′ that extends from the foot/leg 3255′region. In any of the devices described herein, including the variationshown in FIGS. 32A-32G, the device is symmetric along thedistal-to-proximal axis, so that there are pairs of parallel lumen andopenings, as shown.

When the sheath body is coupled to the endotracheal tube, the first,second and third distal openings are configured to be positionedadjacent to the outside of the endotracheal tube so and are separatedfrom each other by at least 0.4 inches. This spacing is configured topermit the distal openings to be positioned in the upper oral cavity,the middle or lower oral cavity and the oropharyngeal regions of thepatient, outside of the endotracheal tube. Regions further distal to theoral cavity (e.g., the subglottic region) may be suctioned by one ormore lumen that are part of the endotracheal tube, as discussed above inreference to FIG. 31A. Thus, any of the respiratory insertion devicesdescribed herein may be configured for insertion primarily into the oralcavity. As mentioned above, the respiratory insertion device such asthat shown in FIG. 32A-32G may be configured for single-use and may bedisposable. The device may be configured to slide over an existingendotracheal tube. For example, the distal part (the extension andsheath body) may be inserted over the endotracheal tube with the flatpart of the extension of the respiratory insertion device facing thetongue; the device may be pushed into the oral cavity over theendotracheal tube until the proximal hard bite flange reaches thepatient's teeth (e.g., incisor teeth). The legs of distal part may bemade of soft biocompatible material (e.g., silicon, etc.) to avoidinjury to mucous membrane and reach the level just above the epiglottisafter complete insertion.

In general, these apparatuses may be configured in different sizesdepending on anatomical variations of individuals. The example show inFIGS. 32A-32G has six lumen (e.g., conduits) integrated into the body,which may be controlled by any of the systems described herein forsuctioning and lavage. In the example shown in FIG. 32A-32G, four lumenout of six (e.g., 3223, 3223′, 3225, 3225′) are used to suctionsecretions from the oral and oropharyngeal regions, and two of the lumen(3221, 3221′) that end in the front of the oral cavity when inserted asdescribed may be used for sprinkling antiseptic solution into the oralcavity. The hard flange of bite flange may also prevent biting ofendotracheal tube by the patients.

As shown in FIGS. 32A and 32B, the distal openings for the oral cavityare protected by tongue protection flaps 3274, 3274′, so that tonguewill not get injured by the suctioning into these distal openings.

FIG. 32B shows the same apparatus of FIG. 32A in a side perspectiveview. Similarly, FIG. 32C shows a view looking down the distal toproximal axis, showing the channel 3205 into which the sheath body, andtherefore the device, may engage over the endotracheal tube. FIGS. 32Dand 32E show top and bottom views, respectively, of the same deviceembodiment. FIG. 32F shows a side view of the respiratory insertiondevice 3201.

The distal end of the device may include a pair of rounded foot or legregions 3255, 3255, which provide support for the distal end openings ofthe oral and oropharyngeal suction ports. These foot regions 3255, 3255′are flattened, teardrop-shaped regions that support the distal endopenings and provide a soft, non-traumatic insertion end for the device,so that the distal end of the device may be easily inserted into thepatient's oral cavity around the catheter. The two foot regions form achannel between them and the flattened (or slightly curved) bottom ofthe extension region that may be easily slid over the endotracheal tube,loosely enclosing and guiding it on three sides; at the more proximalend of the device, the more enclosed channel 3205 through the sheathbody may secure onto the endotracheal tube. Because this region is oneof the last regions to be positioned when inserting the device, it maybe secured last, and make it substantially easier to attach to theendotracheal tube.

FIG. 33 shows another example of a portion of a respiratory insertiondevice similar to that of FIGS. 32A-32F. In the variations shown in FIG.33 , the bite flange 3305 extending proud of the sheath body 3303. Boththe sheath body and the bite flange may be somewhat flatter compared tothe variation shown in FIG. 32A. In FIG. 33 , only a single pair oflumen (e.g., fluid lines) is shown, however additional lumen may beincluded. In FIG. 33 , the lumen forms a suction tube 3315 that includesone or more suction ports 3317 at the distal end.

In FIG. 33 , the bite flange may also include one or more patientconnectors 3335 for securing the device to the patient's head. In FIG.33 , the patient connector 3335 is a strap that may be strapped aroundthe back of the patient's head to hold the respiratory insertion devicein the patient's mouth in the correct location.

In general, the respiratory insertion devices such as those shown inFIGS. 19A-27, 32A-32F, and 33 may be used (“stand alone”) withoutneeding to be attached to an endotracheal tube, although each of them isalso adapted for use with an endotracheal tube. In particular thevariations shown in FIGS. 32A and 33 are particularly well suited forstand-alone use. Further, any of these apparatuses may be used inpatients who are not on a ventilator but still require secretions andoral hygiene management, such as patients recovering from a stroke.

Method of using the fluid management system with the respiratoryinsertion devices

The following paragraphs describe the method of using the fluidmanagement system and with the respiration insertion device. A user caninsert a respiratory insertion device having a plurality of openingsinto a subject's respiratory tract so that a first opening is positionedat oral cavity (e.g., near a base of the subject's tongue), a secondopening is positioned at the subject's oropharynx, and a third openingis positioned at the subject's subglottic region. In one case, therespiratory insertion body attaches to a pre-existing tracheal tube,while in other cases, the respiratory insertion body incorporating atracheal tube, is newly inserted into a patient's trachea.

Next, the user coupling the respiratory insertion body to a controllerby connecting a first lumen of the respiratory insertion body that is incommunication with the first opening to a first fluid line, connecting asecond lumen of the respiratory insertion body that is in communicationwith the second opening to a second fluid line, and connecting a thirdlumen of the respiratory insertion body that is in communication withthe third opening to a third fluid line. The operator then can set thecontroller to automatically, at a predetermined time period, applysuction through each of the first, second and third fluid lines, andautomatically turn off suction in one or the first, second or thirdfluid lines when fluid flow through one of the fluid lines falls below aflow threshold and when pressure in that fluid line is above a pressurethreshold, and applying positive pressure in that fluid line to clear ablockage when fluid flow through that fluid line falls below the flowthreshold and when pressure is below the pressure threshold. Theoperator can also choose to engage a lavage liquid to various regionsalong the tracheal tube.

When a feature or element is herein referred to as being “on” anotherfeature or element, it can be directly on the other feature or elementor intervening features and/or elements may also be present. Incontrast, when a feature or element is referred to as being “directlyon” another feature or element, there are no intervening features orelements present. It will also be understood that, when a feature orelement is referred to as being “connected”, “attached” or “coupled” toanother feature or element, it can be directly connected, attached orcoupled to the other feature or element or intervening features orelements may be present. In contrast, when a feature or element isreferred to as being “directly connected”, “directly attached” or“directly coupled” to another feature or element, there are nointervening features or elements present. Although described or shownwith respect to one embodiment, the features and elements so describedor shown can apply to other embodiments. It will also be appreciated bythose of skill in the art that references to a structure or feature thatis disposed “adjacent” another feature may have portions that overlap orunderlie the adjacent feature.

Terminology used herein is for the purpose of describing particularembodiments only and is not intended to be limiting of the invention.For example, as used herein, the singular forms “a”, “an” and “the” areintended to include the plural forms as well, unless the context clearlyindicates otherwise. It will be further understood that the terms“comprises” and/or “comprising,” when used in this specification,specify the presence of stated features, steps, operations, elements,and/or components, but do not preclude the presence or addition of oneor more other features, steps, operations, elements, components, and/orgroups thereof. As used herein, the term “and/or” includes any and allcombinations of one or more of the associated listed items and may beabbreviated as “/”.

Spatially relative terms, such as “under”, “below”, “lower”, “over”,“upper” and the like, may be used herein for ease of description todescribe one element or feature's relationship to another element(s) orfeature(s) as illustrated in the figures. It will be understood that thespatially relative terms are intended to encompass differentorientations of the device in use or operation in addition to theorientation depicted in the figures. For example, if a device in thefigures is inverted, elements described as “under” or “beneath” otherelements or features would then be oriented “over” the other elements orfeatures. Thus, the exemplary term “under” can encompass both anorientation of over and under. The device may be otherwise oriented(rotated 90 degrees or at other orientations) and the spatially relativedescriptors used herein interpreted accordingly. Similarly, the terms“upwardly”, “downwardly”, “vertical”, “horizontal” and the like are usedherein for the purpose of explanation only unless specifically indicatedotherwise.

Although the terms “first” and “second” may be used herein to describevarious features/elements (including steps), these features/elementsshould not be limited by these terms, unless the context indicatesotherwise. These terms may be used to distinguish one feature/elementfrom another feature/element. Thus, a first feature/element discussedbelow could be termed a second feature/element, and similarly, a secondfeature/element discussed below could be termed a first feature/elementwithout departing from the teachings of the present invention.

Throughout this specification and the claims which follow, unless thecontext requires otherwise, the word “comprise”, and variations such as“comprises” and “comprising” means various components can be co-jointlyemployed in the methods and articles (e.g., compositions and apparatusesincluding device and methods). For example, the term “comprising” willbe understood to imply the inclusion of any stated elements or steps butnot the exclusion of any other elements or steps.

Although various illustrative embodiments are described above, any of anumber of changes may be made to various embodiments without departingfrom the scope of the invention as described by the claims. For example,the order in which various described method steps are performed mayoften be changed in alternative embodiments, and in other alternativeembodiments one or more method steps may be skipped altogether. Optionalfeatures of various device and system embodiments may be included insome embodiments and not in others. Therefore, the foregoing descriptionis provided primarily for exemplary purposes and should not beinterpreted to limit the scope of the invention as it is set forth inthe claims.

The examples and illustrations included herein show, by way ofillustration and not of limitation, specific embodiments in which thesubject matter may be practiced. As mentioned, other embodiments may beutilized and derived there from, such that structural and logicalsubstitutions and changes may be made without departing from the scopeof this disclosure. Such embodiments of the inventive subject matter maybe referred to herein individually or collectively by the term“invention” merely for convenience and without intending to voluntarilylimit the scope of this application to any single invention or inventiveconcept, if more than one is, in fact, disclosed. Thus, althoughspecific embodiments have been illustrated and described herein, anyarrangement calculated to achieve the same purpose may be substitutedfor the specific embodiments shown. This disclosure is intended to coverany and all adaptations or variations of various embodiments.Combinations of the above embodiments, and other embodiments notspecifically described herein, will be apparent to those of skill in theart upon reviewing the above description.

What is claimed is:
 1. A system for automatically removing fluid frommultiple regions of a respiratory tract and lavaging an oral cavityportion of the respiratory tract, the system comprising: a controllercomprising: controller circuitry, a first pressure sensor, a secondpressure sensor, a third pressure sensor, a first port in communicationwith the first pressure sensor and configured to connect to a firstfluid line, a second port in communication with the second pressuresensor and configured to connect to a second fluid line, a third port incommunication with the third pressure sensor configured to connect to athird fluid line, and one or more valves configured to couple to asource of air pressure; a first optical flow sensor configured to coupleto an outside of a first fluid line to detect flow within the firstfluid line; a second optical flow sensor configured to couple to asecond fluid line to detect flow within the second fluid line; a thirdoptical flow sensor configured to couple to a third fluid line to detectflow within the third fluid line; wherein the first second and thirdoptical sensors are housed separately from the controller; furtherwherein the controller circuitry is configured to detect when fluidlines are connected to each of the first, second and third ports, and toperiodically apply negative pressure to each of the first, second andthird ports when fluid lines are detected, and to stop applying negativepressure on the first port when the first optical flow sensor indicatesthere is no more flow, to stop applying negative pressure on the secondport when the second optical flow sensor indicates there is no moreflow, and to stop applying negative pressure on the third port when thethird optical flow sensor indicates there is no more flow; furtherwherein the controller circuitry is configured to detect a blockage inthe first fluid line based on the first pressure sensor and the firstoptical flow sensor, to detect a blockage in the second fluid line basedon the second pressure sensor and the second optical flow sensor, and todetect a blockage in the third fluid line based on the third pressuresensor and the third optical flow sensor, and to clear a detectedblockage.
 2. The system of claim 1, wherein the controller is housed ina control housing enclosing the controller circuitry, the first, secondand third pressure sensors, and the one or more valves.
 3. The system ofclaim 1, wherein the first, second and third optical flow sensors arehoused in a flow sensor housing configured to be applied around thefirst, second and third fluid lines near a patient's head.
 4. The systemof claim 1, wherein the controller is configured to apply positivepressure to deliver a lavage fluid out of the first port and to applynegative pressure to the first, second and third port to remove thelavage fluid when fluid lines are detected.
 5. The system of claim 1,wherein the one or more valves comprises a first, second and thirdsuction valves.